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Full Description
Fully updated to reflect the latest practice and reporting requirements, The Psychotherapy Documentation Primer, Third Edition is the benchmark record-keeping reference for 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.
Contents
Preface vii How This Book Came Into BeingBad 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
