The Psychotherapy Documentation Primer

by Wiger, Donald E.

• ISBN13: 9780470903964
• ISBN10: 0470903961
• Edition: 3rd
• Format: Paperback
• Copyright: 2011-12-20
• Publisher: Wiley

Summary

Fully updated to reflect the latest practice and reporting requirements, The Psychotherapy Documentation Primer, Third Edition is the benchmark record-keeping reference for working mental health professionals. It demystifies the entire documentation process and includes everything a therapist needs to know to record client intake, treatment, and progress. New chapters are included on the art and science of psychological assessment and treatment, and ethical considerations in documentation. Mental health practitioners and graduate students will find the latest information on regulations affecting managed care, accrediting agencies, and the government.

Author Biography

Donald E. Wiger, PHD, is a practicing psychologist in St. Paul, Minnesota, specializing in conducting psychological evaluations for a variety of purposes. He has taught graduate courses in psychological assessment for over twenty years and has written several texts in the areas of documentation, clinical forms, interviewing, outcomes, and crisis intervention. He conducts seminars nationally in areas such as documentation, interviewing, and private practice.

Table of Contents

Preface	p. vii
How This Book Came Into Being: A Lesson in Making a Really Bad Negative Into a Really Good Positive	p. ix
Introduction	p. 1
The Art and Science of Psychological Assessment and Treatment	p. 5
Overview of Current Documentation Procedures and Third-Party Requirements	p. 11
Ethical Considerations in Documentation	p. 35
The Biopsychosocial Assessment	p. 47
The Mental Status Exam	p. 81
Validating a Diagnosis	p. 95
Formulating a Treatment Plan	p. 117
Writing Progress Notes	p. 145
Documenting the Need for Additional Services	p. 175
Putting it All Together: Documented Chart for Mental Health Services	p. 181
Overview of Outcome Measures	p. 201
Overview of HIPAA Guidelines in Mental Health Settings	p. 207
Glossary	p. 211
References and Suggested Readings	p. 221
Index	p. 225
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