The Clinical Documentation Sourcebook

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.

Accompanying floppy disk contains ... "24 ready-to-use sample forms that meet the documentation requirements of virtually every managed care organization."--Page 4 of cover.

All the forms, handouts, and records you need to meet the paperwork requirements of the managed care era In an era of third-party accountability, your professional survival could hinge on your ability to comply with the documentation requirements of insurers and regulatory agencies. Written by an experienced clinician who has trained thousands of mental health professionals in effective clinical documentation, this sourcebook helps you minimize the potential for billing disputes–or worse–by arming you with the full retinue of required forms, checklists, and records. An indispensable resource for mental health professionals working in inpatient, partial hospitalization, day treatment, and/or residential treatment programs, The Continuum of Care Clinical Documentation Sourcebook is the only book that brings together sample documents covering all stages of treatment–from intake and admission to outcome assessment. 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

All of the forms, inventories, checklists, client handouts, and clinical records essential to building and running a successful practice. Has the paperwork monster created by today's managed care environment crippled your couple and family practice? This handy sourcebook—the first in this discipline—is the timesaving resource you've been looking for. It provides couple and family therapists with a full arsenal of tools for assessing and treating clients' problems, and managing today's complicated practices. Providing ready-to-copy blank forms, examples of fully completed forms, and a floppy disk containing all of the blank forms in ready-to-use word-processing files, this invaluable resource will assist you in effectively and efficiently providing services. With The Couple and Family Clinical Documentation Sourcebook you'll spend less time on paperwork and more time with clients. All of the forms, inventories, checklists, client handouts, clinical records, and guidelines essential to building and running a successful practice Ready-to-use blank forms and handouts 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.

An ideal companion to Dr. Wiger's well-received forms book, The Clinical Documentation Sourcebook, as well as the Psychotherapy Treatment Planners, this book explains the rationale behind, and the most efficient approach to, the paperwork required when providing mental health services in the era of managed care. This reference covers every stage of the treatment process, from the initial assessment to diagnosis, psychological reports, treatment plans, and progress notes. No clinician or trainee can afford to be without this accessible reference.

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.

All the forms, checklists, handouts, and clinical records needed to run a successful child mental health practice The paperwork required when providing mental health services in the current era of third-party accountability continues to mount. This easy-to-use resource offers child psychologists and therapists a full array of forms, inventories, checklists, client handouts, and clinical records essential to a successful practice in either an organizational or clinical setting. From intake to diagnosis and treatment through discharge and outcomes assessment, The Clinical Child Documentation Sourcebook offers sample forms for every stage of the treatment process. Like its bestselling predecessor, The Clinical Documentation Sourcebook, The Clinical Child Documentation Sourcebook includes ready-to-copy blank forms, as well as examples of fully completed forms, and a 3.5" disk that contains word-processing versions of every form in the book. With The Clinical Child 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 disk included using any DOS or Windows-based word-processing program