The Psychotherapy Documentation Primer

by Donald E. Wiger

Overview

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.

Product Details

ISBN-13:	9781119709848
Publisher:	Wiley
Publication date:	12/03/2020
Edition description:	4th ed.
Pages:	288
Sales rank:	837,574
Product dimensions:	6.90(w) x 9.90(h) x 0.70(d)

About the Author

DONALD E. WIGER, Ph.D., is a practicing psychologist in St. Paul, MN, specializing in conducting psychological evaluations for a variety of purposes. He has taught graduate courses in psychological assessment for over 30 years. He has written several texts in areas of documentation, clinical forms, interviewing, outcomes, and crisis intervention. He conducts seminars, nationally, in areas such as documentation, interviewing, and private practice.

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Table of Contents

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 9

3 Overview of Current Documentation Procedures and Third-Party Requirements 15

4 Ethical Considerations in Documentation 45

5 The Biopsychosocial Assessment 59

6 The Clinical Interview: Mental Status Exam 93

7 The Clinical Interview: Validating a Diagnosis 111

8 Formulating a Treatment Plan 135

9 Writing Progress Notes 163

10 Documenting the Need for Additional Services 195

11 Documenting Mental Health Treatment Outcomes for Individuals 201

Appendix A Putting it all Together: Documented Chart for Mental Health Services 213

Appendix B Overview of HIPAA Guidelines in Mental Health Settings 233

Appendix C Example of Corrective Actions Due to a Therapist’s Poor Documentation 237

Appendix D Documenting Suicidality 241

Glossary 245

References and Suggested Readings 253

Index 257

Editorial Reviews

Reviewer: Gary B Kaniuk, PsyD (Cermak Health Services)
Description: This book focuses on developing skills for good documentation in mental health practice. It looks at assessment, third party payment issues, ethics, treatment planning, and writing basic progress notes. It incorporates HIPAA standards and best practices. This is the fourth edition, last published in 2011.
Purpose: According to the preface, the book "is designed to teach documental skills for the course of psychotherapy from the initial interview to the discharge" (p. vii). These are very worthy objectives, which the book meets.
Audience: According to the book, "the readership is intended for both students and professionals in the mental health field" (p. vii). The book meets the needs of its intended audience. The author is a credible authority in the subject matter of the book. He is employed in private practice and conducts psychological evaluations. He has taught in graduate school for over 30 years, has published different texts regarding documentation, and conducts seminars.
Features: The book begins with an introduction to the topic. It is important to accurately document the goals and outcomes of therapy, which is demanded from state boards and insurance panels. Though there are different schools of thought on how therapy should proceed, documentation should be atheoretical. Good documentation will protect the clinician and demonstrate accountability. Therapists must avoid potential dual relationships and provide informed consent, including limits of confidentiality, before treatment commences. The biopsychosocial model is a good way to obtain a comprehensive history. The assessment should also include a mental status examination. The clinician should be well versed in the DSM 5 (Diagnostic and Statistical Manual of Mental Disorders) since diagnosis drives treatment. A treatment plan is developed in the early sessions of therapy but can be modified when necessary. After the session, a progress note is written, which is the evidence of interventions used and treatment efficacy. Documentation can impact the potential of additional sessions being allowed by insurance carriers. Finally, outcome data is the evidence that is used to show that treatment is working (or needs to be modified). The book is very readable and contains helpful figures, which clarify the text. The chapters are organized in a uniform manner with text, highlights, and questions. There are also clinical examples that show how the information presented can be used. There are no obvious shortcomings of the book.
Assessment: This book is excellent because it gives a step-by-step approach to documentation of mental health treatment. It discusses in depth the interview process and how to develop treatment plans. It shows the importance of documentation in order to satisfy state licensing boards and third-party payors, utilizing HIPAA standards. The fourth edition justifies replacing the third because the chapters have been updated, utilizing DSM 5 criteria.

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