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.

"...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 practice groups, inpatient facilities, and hospitals...second edition provides the latest information on record keeping for intake, assessment, treatment planning, progress notes, and other essential areas..."--back cover.

All the forms, handouts, and records mental health professionals need to meet documentation requirements–fully revised and updated 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. Now fully updated and revised, the Fourth Edition of The Clinical Documentation Sourcebook provides you with a full range of forms, checklists, and clinical records essential for effectively and efficiently managing and protecting your practice. The Fourth Edition offers: Seventy-two ready-to-copy forms appropriate for use with a broad range of clients including children, couples, and families Updated coverage for HIPAA compliance, reflecting the latest The Joint Commission (TJC) and CARF regulations A new chapter covering the most current format on screening information for referral sources Increased coverage of clinical outcomes to support the latest advancements in evidence-based treatment A CD-ROM with all the ready-to-copy forms in Microsoft® Word format, allowing for customization to suit a variety of practices From intake to diagnosis and treatment through discharge and outcome assessment, The Clinical Documentation Sourcebook, Fourth Edition offers sample forms for every stage of the treatment process. Greatly expanded from the Third Edition, the book now includes twenty-six fully completed forms illustrating the proper way to fill them out. Note: CD-ROM/DVD and other supplementary materials are not included as part of eBook file.

Avoid malpractice for keeping inadequate records and be prepared to respond to a professional peer review by using Documenting Psychotherapy, a practical volume that examines what is necessary in order to keep adequate records that meet current standards of care. This highly readable volume explores issues such as the limits of confidentiality, retention and disposition of records, documentation of safety issues, client access to records, treatment of minors, and the clinical record as it pertains to working with individuals, family couples and groups, as well as supervision and training issues are discussed in detail. Legal cases, vignettes and professional commentary are used throughout the book in order to help guide the reader in thinking through legal and ethical situations. Documenting Psychotherapy belongs on the book shelf of every mental health practitioner and will prove invaluable to professionals in clinical/counseling psychology, social work, psychology, interpersonal violence, and nursing.

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 Fourth Edition of The Psychotherapy Documentation Primer continues to reflect HIPAA and accreditation agency requirements as well as offer an abundance of examples. Fully updated to include diagnostic criteria of the DSM-5, The Psychotherapy Documentation Primer, 4th Edition is designed to teach documental skills for the course of psychotherapy from the initial interview to the discharge. The documentation principles discussed in the text satisfy the often-rigid requirements of third-party insurance companies, regulating agencies, mental health licensing boards, and federal HIPAA regulations. More importantly, it provides students and professionals with the empirical and succinct documentation techniques and skills that will allow them to provide clear evidence of the effects of mental health treatment while also reducing the amount of their time spent on paperwork.

This guide practically aids mental health professionals in understanding and improving their therapeutic and academic writing, demonstrating how the written word is an invaluable tool to document, assess, and promote change with those in and outside the therapy room. Exploring the various ways writing occurs in psychotherapy professions, Michael D. Reiter comprehensively covers the range of the written word, from progress notes and assessment documentation, to journaling and therapeutic letters, as well as contacting larger systems such as report writing and grant applications. Chapters are formatted to include the purpose and function of a particular type of writing before providing multiple examples so therapists can apply this in their own practice. This book aims to help all therapists, regardless of academic training or therapeutic modality, to incorporate these ideas into their work. This book is designed for mental health professionals in a variety of settings, including counselors, therapists, social workers, family therapists, and clinical psychologists. This book is useful for graduate students as well as those already in practice.

All the forms, handouts, and records a mental health professional needs to meet the documentation requirements of the managed care era The paperwork required when providing mental health services in the current era of third-party accountability continues to mount. This updated and revised Second Edition keeps today's mental health professionals on top of all the latest developments by providing a full arsenal of forms, checklists, and clinical records essential to effectively manage a practice. From intake to diagnosis and treatment through discharge and outcomes assessment, The Clinical Documentation Sourcebook offers sample forms for every stage of the treatment process. Expanded by 30% from the first edition, the book now includes 30 fully completed forms as well as 36 ready-to-copy blank forms that are also provided on disk so they may be easily customized. With The Clinical Documentation Sourcebook you'll spend less time on paperwork and more time with clients. Ready-to-use blank forms, handouts, and records make it easy to satisfy the paperwork demands of HMOs, insurers, and regulatory agencies Completed copies of forms illustrate the exact type of information required Clear, concise explanations of the purpose of each form—including when it should be used, with whom, and at what point Forms may be copied from the book or customized on the included disk