The Clinical Documentation Sourcebook: The Complete Paperwork Resource for Your Mental Health Practice » (4th Edition)

DONALD E. WIGER, PHD, a psychologist, runs a large mental health clinic in St. Paul and is an adjunct professor at Argosy University School of Professional Psychology. He is the author of numerous books, including The Psychotherapy Documentation Primer, also from Wiley.

All the forms, handouts, and records mental health professionals need to meet documentation requirements

The paperwork required when providing mental health services continues to mount. Keeping records for managed care reimbursement, accreditation agencies, protection in the event of lawsuits, and to help streamline patient care in solo and group practices, inpatient facilities, and hospitals has become increasingly important. This updated and revised Third Edition provides you with a full range of forms, checklists, and clinical records essential for effectively and efficiently managing your practice.

From intake to diagnosis and treatment through discharge and outcome assessment, The Clinical Documentation Sourcebook, Third Edition offers sample forms for every stage of the treatment process. Greatly expanded from the second edition, the book now includes twenty-six fully completed forms illustrating the proper way to fill them out, as well as fifty-two ready-to-copy blank forms. The included CD-ROM also provides these forms in Word format so you can easily customize them to suit your practice. With The Clinical Documentation Sourcebook, Third Edition, you’ll spend less time on paperwork and more time with clients.

• Includes documentation for child, family, and couples counseling

• Updated for HIPAA compliance, as well as to reflect the latest JCAHO and CARF regulations

• New focus on clinical outcomes supports the latest innovations in evidence-based practice

CD Contents.

Acknowledgments.

Preface.

Introduction.

Chapter 1. Administrative and Intake Forms.

Chapter 2. Forms Designed for HIPAA Compliance.

Chapter 3. Assessment Forms.

Chapter 4. Psychological Evaluations.

Chapter 5. Treatment Planning Forms and Procedures.

Chapter 6. Progress Notes.

Chapter 7. Other Forms Used During the Course of Treatment.

Chapter 8. Chart Review and Outcomes Documentation.

Chapter 9. Termination and Aftercare.

Bibliography and Suggested Readings.

CD-ROM Information