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Short description 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.
From the contents Chapter 1 Introduction
Chapter 2 The Art and Science of Psychological Assessment and Treatment
Chapter 3 Overview of Current Documentation Procedures and Third Party Requirements
Chapter 4 Ethical Considerations in Documentation
Chapter 5 The Biopsychosocial Assessment
Chapter 6 The Mental Status Exam
Chapter 7 Validating a Diagnosis
Chapter 8 Formulating a Treatment Plan
Chapter 9 Writing Progress Notes
Chapter 10 Documenting the Need for Additional Services
Appendix A Putting it all Together: Documented Chart for Mental Health Services
Appendix B Overview of Outcome Measures
Appendix C Overview of HIPAA Guidelines in Mental Health Settings