Proper clinical record-keeping has always been important, but in the managed care era, it is a matter of professional survival. Unfortunately, most mental health practitioners learn it the hard way, through costly trial and error. Not any more. Written by an experienced clinician who has trained thousands of colleagues in effective clinical record-keeping, ... [this book] substantially reduces the learning curve with a sensible approach to psychological documentation guaranteed to help you:
Spend less time doing paperwork
Fully satisfy the requirements of third-party payers and regulatory agencies
Minimize the risk of insurer noncompliance and audits
Keep therapy on target
Using many instructive examples of both effective and ineffective clinical records, this book explains the rationale behind -- and most efficient approach to -- tackling each component of psychological documentation. And it provides clear, easy-to-follow directions on how to create comprehensive patient files that span the entire therapy cycle--from inital assessment to diagnosis, psychological reports, treatment plans, progress notes, and outcome.
Donald E. Wiger, PhD, is a practicing psychologist in St. Paul, Minnesota, specializing in conducting psychological evaluations for a variety of purposes. He has taught graduate courses in psychological assessment for over twenty years and has written several texts in the areas of documentation, clinical forms, interviewing, outcomes, and crisis intervention. He conducts seminars nationally in areas such as documentation, interviewing, and private practice.
Overview of Current Documentation Procedures and Third-Party Requirements.
The Biopsychosocial Assessment.
The Mental Status Exam.
Validating a Diagnosis.
Documenting the Need for Additional Services.
Bibliography and Suggested Readings.