The Psychotherapy Documentation Primer

Everything you need to know to record client intake, treatment, and progress—incorporating the latest managed care, accrediting agency, and government regulations Paperwork and record keeping are day–to–day realities in your mental health practice. Records must be kept for managed care reimbursement; for accreditation agencies; for protection in the event of lawsuits; to meet federal HIPAA regulations; and to help streamline patient care in larger group practices, inpatient facilities, and hospitals. The standard professionals and students have turned to for quick and easy, yet comprehensive, guidance to writing a wide range of mental health documents, the Third Edition of The Psychotherapy Documentation Primer continues to reflect HIPAA and accreditation agency requirements as well as offer an abundance of examples. The new edition features: Revised examples of a wider range of psychological concerns New chapters on documentation ethics and the art and science of psychological assessment and psychotherapy Study questions and answers at the end of each chapter Greatly expanded, The Psychotherapy Documentation Primer, Third Edition continues to be the benchmark record–keeping reference for working professionals, reflecting the latest in documentation and reporting requirements.

Preface vii How This Book Came Into Being: A Lesson in Making a Really Bad Negative Into a Really Good Positive ix 1 Introduction 1 2 The Art and Science of Psychological Assessment and Treatment 5 3 Overview of Current Documentation Procedures and Third–Party Requirements 11 4 Ethical Considerations in Documentation 35 5 The Biopsychosocial Assessment 47 6 The Mental Status Exam 81 7 Validating a Diagnosis 95 8 Formulating a Treatment Plan 117 9 Writing Progress Notes 145 10 Documenting the Need for Additional Services 175 Appendix A Putting it All Together: Documented Chart for Mental Health Services 181 Appendix B Overview of Outcome Measures 201 Appendix C Overview of HIPAA Guidelines in Mental Health Settings 207 Glossary 211 References and Suggested Readings 221 Index 225

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.