The Psychotherapy Documentation Primer / Edition 3

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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.

The book contains black-and-white illustrations.

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Editorial Reviews

From the Publisher
"This book is an invaluable reference guide for starting therapists who would like to learn good habits in the standards and practice of record management, as well as seasoned therapists who would like to improve their own client documentation practices." (Metapsychology, May 2007)
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Product Details

  • ISBN-13: 9780470903964
  • Publisher: Wiley
  • Publication date: 12/27/2011
  • Series: PracticePlanners Series , #279
  • Edition number: 3
  • Pages: 252
  • Sales rank: 666,868
  • Product dimensions: 6.90 (w) x 9.90 (h) x 0.70 (d)

Meet the Author

Donald E. Wiger, PhD, is a practicing psychologist in St. Paul,Minnesota, specializing in conducting psychological evaluations fora variety of purposes. He has taught graduate courses inpsychological assessment for over twenty years and has writtenseveral texts in the areas of documentation, clinical forms,interviewing, outcomes, and crisis intervention. He conductsseminars 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 BadNegative Into a Really Good Positive ix

1 Introduction 1

2 The Art and Science of Psychological Assessment and Treatment5

3 Overview of Current Documentation Procedures and Third-PartyRequirements 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 MentalHealth Services 181

Appendix B Overview of Outcome Measures 201

Appendix C Overview of HIPAA Guidelines in Mental HealthSettings 207

Glossary 211

References and Suggested Readings 221

Index 225

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