The Clinical Documentation SourceBook with disk (for Adults)

The Clinical Documentation SourceBook with disk (for Adults)

by Donald E. Wiger

Paperback(Older Edition)


Product Details

ISBN-13: 9780471326922
Publisher: Wiley
Publication date: 02/28/1999
Series: PracticePlanners Series , #23
Edition description: Older Edition
Pages: 304
Product dimensions: 8.48(w) x 11.06(h) x 0.81(d)

About the Author

Donald E. Wiger, PhD, is a psychologist with a successful private practice. He teaches graduate courses at the Minnesota School of Professional Psychology. Through his company, CPS Seminars, he also conducts workshops training other mental health professionals in psychological assessment and clinical documentation.

Read an Excerpt

The Clinical Documentation Sourcebook
A Comprehensive Collection of Mental Health Practice Forms, Handouts, and Records
Second Edition

Donald E. Wiger

(The forms mentioned in this sample chapter do not appear on the web version.)

Chapter 1
Intake and Termination Forms and Procedures

The mental health clinic's intake information forms elicit demographic and payment information about the client. They also communicate business, legal, and ethical issues and responsibilities. Although initial intake forms do not provide specific clinical information, they do provide an understanding of the responsibilities of both the client and the clinic. In each case, these forms are taken care of prior to the first counseling session. All insurance and financial agreements are contracted with the client before services begin. The clinic's financial policies must be clearly spelled out. In addition, the client should be made aware of, and agree to, the limits of confidentiality in a counseling session.
Common client questions are: "What if my insurance company does not pay?," "How confidential is the session?," "Do parents have the right to their children's records?," "What happens if payment is not received?," "What happens if suicide is mentioned?," and "What is the price of therapy?" These and other questions are not only answered, but also documented and signed. Any of these issues, if not covered, could lead to misunderstanding, subsequent premature termination of treatment, ethics changes, or a lawsuit. Intake forms provide clear communication between the client and clinic, with the aim of eliminating misunderstandings detrimental to the therapeutic process and clinic survival.

Initial Client Information Form
The initial intake information form (Form 1) is filled out at the time of the referral or initial client contact with the mental health care provider. Information solicited from the client includes basic demographic, plus insurance identification information. For insurance reasons, information requested from the client should minimally include:

  • Policyholder information: name, date of birth, social security number, policy number.
  • Similar information from family members receiving services.
  • Name of employer.
  • Name and telephone number of each third-party payer.
If the mental health care provider processes insurance information, it is crucial to verify benefits from the insurance company. Specific questions should be asked of the third party, minimally including the following:
  • Persons covered by the policy.
  • Deductible amount and amount currently satisfied.
  • Co-payment amounts.
  • Limits of policy.
  • Covered/noncovered services (e.g., individual, family, relationship).
  • Prior authorizations needed.
  • Coverage and policies for testing.
  • Supervision required for various providers.
  • Type(s) of provider(s) covered for services (e.g., psychologist, social worker counselor).
  • Policy anniversary date.
When this information is unclear or unknown, there is room for misunderstanding between the mental health care provider and the client. Clients usually believe that all services performed in therapy are covered by their insurance. But mental health benefits from several sources are decreasing, and only specific, limited services are now covered. For example, just a few years ago several third-party payers paid for testing; today testing is seldom considered a standard procedure and often needs prior approval. Another trend is that most managed-care companies approve only a few sessions at a time, while in the past few restrictions were made.
Initial insurance information provided by third-party payers is not a guarantee of benefits. Each mental health care provider should have a clear financial policy and payment contract (possibly on the same form) to explain conditions of payment in the event that the third-party payer denies payment.

Financial Policy Statement
Clinical skills are necessary, but not the sole component in the overall scope of mental health services. A concise, written financial policy is crucial to the successful operation of any practice. Clear financial policies and procedures eliminate much potential discord (and premature termination of services) between the client and the therapist and clinic. Clinics that thrive financially and are self-sufficient have few accounts receivable at any time. An adequate financial policy statement addresses the following:

  • The client is ultimately responsible for payment to the clinic. The clinic can not guarantee insurance benefits. (Note: Some managed-care contracts forbid client payment to the clinic for noncovered services without permission.)
  • Clinics that bill insurance companies should convey to clients the fact that billing third-party payers is simply a service-not a responsibility-of the clinic.
  • There are time limits in waiting for insurance payments, after which the client must pay the clinic. Some clinics collect the entire amount initially from the client and reimburse the client when insurance money is received.
  • The clinic's policy regarding payment for treatment of minors should be noted.
  • The policy regarding payment for charges not covered by third-party payers should be addressed.
  • The financial policy form should be signed by the person(s) responsible for payment.
  • Assignment of benefit policies should be addressed.
  • The financial policy statement should specify when payments are due and policies for nonpayment.
  • Methods of payment should be listed.
Request clients to read and sign the financial policy statement (Form 2) prior to the first session. Some mental health providers ask clients to come to the first session 15 to 20 minutes early to review the initial policies and procedures. Take care of all financial understandings with the client before the first session begins; otherwise, valuable session time might be taken up reviewing financial issues.

Payment Contract for Services
Along with the financial policy statement, the payment contract is vital for the clinic's financial survival. Without a payment contract, clients are not clearly obligated to pay for mental health services. The following payment contract meets federal criteria for a truth in lending disclosure statement for professional services and provides a release of information to bill third parties (Form 3).
The contract lists professional fees that will be charged. (A clinical hour should be defined by the number of minutes it covers rather than stating "per hour "). Interest rates on late payments must be disclosed. Other services provided by the mental health care provider must also be listed, and costs should be disclosed. Fees for services such as testing should be listed, either by the test or at an hourly rate for testing and interpretation time. The contract should cover specific clinic policies regarding missed appointments, outside consultations, and other potential fees related to the mental health care provider.
The mental health care provider may choose to include or omit estimated insurance benefits in the payment contract. Since the mental health clinic is not directly affiliated with the third-party payer and their changing policies, it is important to clearly state that payment is due regardless of decisions made by the third-party payer and that the client is financially responsible to the clinic for any amounts not paid by the third-party payer within a certain time frame.

Limits of Confidentiality Form
Accountability in the intake session goes far beyond providing an accurate diagnosis. Legal and ethical considerations must be addressed prior to eliciting personal intake information. As "informed consumers" of mental health services, clients are entitled to know how confidential their records are. Few people are aware of the potential risks of having a recorded Axis I diagnosis and how such a record might adversely affect the client.
While several books have been written regarding the ethics of informed consent, there are additional areas of informed consent usually not addressed in the intake process that could lead to litigation. Therapists should have a written document addressing the limits of confidentiality that is to be signed by the client (Form 4). Thirteen areas of confidentiality are noted below. The first seven are commonly known, while the remaining items are seldom considered.
1. Duty to warn and protect. When a client discloses intentions or a plan to harm another person, health care professionals are required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, health care professionals are required to notify legal authorities and make reasonable attempts to warn the family of the client.
2. Abuse of children and vulnerable adults. If a client states or suggests that he or she is abusing or has recently abused a child or vulnerable adult, or a child or vulnerable adult is in danger of abuse, health care professionals are required to report this information to the appropriate social service and/ or legal authorities.
3. Prenatal exposure to controlled substances. Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. State laws may vary.
4. In the event of a client's death. In the event of a client's death, the spouse or parents of a deceased client have a right to gain access to their child's or spouse's records.
5. Professional misconduct. Professional misconduct by a health care professional must be reported by other health care professionals. If a professional or legal disciplinary meeting is held regarding the health care professional's actions, related records may be released in order to substantiate disciplinary concerns.
6. Court orders. Health care professionals are required to release records of clients when a court order has been issued.
7. Minors/guardianship. Parent or legal guardians of nonemancipated minor clients have the right to gain access to the client's records.
8. Collection agencies. Although the use of collection agencies is not considered unethical, there may be ethical concerns if a client is not informed that the clinic uses collection agencies when fees are not paid in a timely manner. If use of a collection agency causes a client's credit report to list the name of the counseling agency, it is not uncommon for the client to threaten a lawsuit against a therapist claiming the confidentiality has been violated. A clear financial policy signed by the client prior to receiving services in crucial in the operation of a clinic. Clear financial policies and procedures eliminate much potential discord (and premature termination of services) between the client and the therapist and clinic. Clinics which thrive financially and are self-sufficient have few accounts receivable.
9. Third-party payers. Many clients using insurance to pay for services are not aware of potential drawbacks. They may not realize which of their mental health records may be available to third-party payers. Insurance companies may require and be entitled to information such as dates of service, diagnosis, treatment plans, descriptions of impairment, progress of therapy, case notes and summaries. The documented existence of an Axis I diagnosis could have adverse future effects on such areas as insurance benefits.
10. Professional consultations. Clients should be informed if their cases are discussed in staff meetings or professional consultations. Assure them that no identifying information will be disclosed.
11. Typing/dictation services. Confidentiality might be violated when anyone other than the therapist types psychological reports. In many cases office staff have access to records. There have been several cases in which office personnel have reviewed files of relatives, neighbors, and other acquaintances. This is difficult to prevent, so inform clients that clerical personnel might have access to records and are held accountable for confidentiality. Records should be available within a clinic only on a "need to know" basis.
12. Couples, family, and relationship counseling. Separate files should be kept for each person involved in any conjoint or family counseling. If more than one person's records are kept in one file, it is possible that a serious breach of confidentiality could take place. For example, when couples enter counseling for marital issues, there is a potential for divorce and a child custody battle. If one of the partners requests "their file" and receives confidential material about the spouse, confidentiality has been violated. A clear policy indicating the agency's procedures in such situations is needed.
13. Telephone calls, answering machines, and voice mail. In the event that the agency or mental health professional must telephone the client for purposes such as appointment cancellations, reminders, or to give/ receive information, efforts must be made to preserve confidentiality. The therapist should ask the client to list where the agency may phone the client and what identifying information can be used.

Preauthorization for Health Care Form
Charge cards are an effective means of collecting fees for professional services. The following form provides several benefits (Form 5). It allows the clinic to automatically bill the charge-card company for third-party payments not received after a set number of (often 60) days. It eliminates expensive-and often ineffective-billing to the client and successive billing to the insurance company. It further allows the clinic to bill the charge-care company for recurring amounts such as co-payments. This policy is often welcomed by clients because it eliminates the need to write a check each time services are received.
Most banks offer both VISA and MasterCard dealer status, but established credit is needed. Some therapists have become vendors for credit-card companies by offering to back the funds with a secured interest-bearing account (e. g., $500) for a set period while their credit becomes established with the bank.
Fees for being a charge-card dealer vary and may be negotiated, so competitive shopping for a bank is suggested. Some banks charge a set percentage of each transaction, while others include several hidden fees. The process is simpler though when the same bank is used in which the mental health professional has a checking account, because charge account receipts are generally deposited into a checking account.

Release of Information Consent Form
The Release of Information Consent Form incorporates both legal and ethical obligations between the mental health professional and the client (Form 6). No information about clients should be discussed with anyone without that person's written permission, except information listed in the Limits of Confidentiality form (e.g., suicide, abuse, and so forth). A violation of confidentiality could lead to ethical, professional, and legal problems.
Clients have the right to know how the information will be used and which files will be released. A release of information is valid for one year, but may be cancelled at any time.
The legal guardians of children must sign the release. No release is necessary for children who are emancipated. It is necessary to find out if a vulnerable adult has a designated guardian (e.g., state or private guardianship, family).
This release form allows for a two-way release of information (to and from various providers). Some agencies and some clients prefer to fill out a separate release for each transaction.

Suicide Contract
A suicide contract serves several purposes. Although it is not a legal contract, it represents the client's commitment to take responsible actions when feeling suicidal. It is a signed agreement between the client and the therapist that suicide will not take place. It further provides evidence that the therapist has provided help for the client.
Most therapists ask clients to keep the contract with them at all times. It contains important contact telephone numbers that may not otherwise be immediately available or thought of during a crisis period. It also represents the therapist's commitment to the client, by providing means to contact the therapist in times of emergency or crisis.

Discharge Summary Form
The Discharge Summary Form (Form 8) is intended to summarize the effects of therapy. It lists the initial and final diagnoses, dates of service, progress, and reasons for termination. It provides a brief overview of changes in symptomology and the client's level of functioning as the result of therapy. Both the client's and therapist's evaluation are included.
Material from the Discharge Summary is helpful in assessing outcome measures. For example, changes in diagnosis, GAF, and current stressors can provide quantifiable information deemed necessary by several managed care organizations and third-party reviewers. An evaluation of the reasons for termination may help the clinic assess the quality, type, and number of services provided by both individual therapists and the clinic. Such information is helpful in clinic planning.

Termination Letter
The Termination Letter (Form 9) is sent to the client when services from the therapist or clinic are no longer being utilized. It serves at least two purposes. First, it is designed to free the clinic from any responsibility for any of the client's actions (which had nothing to do with the therapy received) after therapy has taken place. A clinic may bear some responsibility for a nonterminated client. Second, it provides a transition point to the client.
Certain ethical principles must be considered at a termination. Terminating a client is not abandoning a client. A proper termination implies that sufficient progress was made or attempted at the clinic, and the client is ready for a change to treatment elsewhere, or has made sufficient progress so that treatment is no longer necessary.
The clinic should provide the client with resources at termination to handle emergencies or crises. There may include crisis hot-line numbers, hospitals, walk-in clinics, or availability of the therapist or clinic in the future. Clearly document in progress notes that this information was provided to the client.
At the time of termination, the therapist should document the reason for termination and the estimated risk of relapse. Relapse is beyond the clinic's control. Therefore, the therapist should assure the client that help is available if needed in the future.
Some therapists suggest that the client receives periodic "booster sessions" such as at 6 months, then 12 months. It is important to clearly explain to a client the purpose of termination and that a termination letter will be sent, even though there may be booster sessions in the future.

Table of Contents

Intake and Termination Forms and Procedures.

Assessment for Counseling Forms and Procedures.

Evaluation Forms and Procedures.

Treatment Plan Forms and Procedures.

Progress Notes and Prior Authorization Request Forms and Procedures.

Relationship Counseling Forms and Procedures.

Bibliography and Suggested Readings.

About the Disk.

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