Everything a therapist needs to know to record client intake, treatment, and progress--fully 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 practice groups, inpatient facilities, and hospitals.?The first edition of The Psychotherapy Documentation Primer became a standard for professionals and students who needed a quick and easy, yet comprehensive, guide to writing a wide range of mental health documents. This updated and revised Second Edition provides the latest information on record keeping for intake, assessment, treatment planning, progress notes, and other essential areas.
Greatly expanded, this user-friendly guide encompasses the many changes that have occurred in mental health practice, including: * Changes to DSM codes and definitions * New managed care guidelines * Accrediting requirements from JCAHO and CARF * New federal HIPAA regulations In addition, the revised text features more instructional tools for classroom use. These include: * More examples and improved graphics * Study questions and answers at the end of each chapter * An expanded reference section Fully updated to reflect the latest practice and reporting requirements, The Psychotherapy Documentation Primer, Second Edition is the benchmark record-keeping reference for working mental health professionals.
1. Introduction. 2. Overview of Current Documentation Procedures and Third-Party Requirements. 3. The Biopsychosocial Assessment. 4. The Mental Status Exam. 5. Formulating and Validating a Diagnosis. 6. Treatment Planning. 7. Progress Notes. 8. Documenting the Need for Additional Services. Appendix A: Documented Client Chart for Judy Doe. Appendix B: Overview of Outcome Measures. Appendix C: Overview of HIPAA Guidelines in Mental Health Settings. Glossary. Bibliography. Index.