the PSYCHOTHERAPY DOCUMENTATION PRIMER

Cover
Title Page
Copyright Page
Contents
Preface
How This Book Came Into Being: A Lesson in Making a Really Bad Negative Into a Really Good Positive
Chapter 1 Introduction
	Highlights of Chapter 1
	Questions
Chapter 2 The Art and Science of Psychological Assessment and Treatment
	The Practice of Mental Health as an Art
	The Practice of Mental Health as a Science
	Integrating the Art and Science of Mental Health
	Documentation in the light of art vs. Science
	Highlights of Chapter 2
	Questions
Chapter 3 Overview of Current Documentation Procedures and Third-Party Requirements
	Comparing what we “ought to do” to what we were “taught to do”
	Mental Health Graduate Training
	Third-Party Payers and Managed Care
	Medical Necessity
	Mental Health Criteria
		Comparison to Documentation in Other Fields
	Criteria for Clinical Significance
	The O-F-A-I-D (of aid) Procedure
		Example of Documentation with O-F-A-I-D Procedure
		Use of the O-F-A-I-D Procedure in Validating a Diagnosis
	Functional Impairments
	Assessment Procedures
	Integrating Conflicting Observations, Client Statements, Mental Status Exam, Previous Records, and Testing
		Current Information
		Psychological Testing
		Collateral Information
		Historical Records
	Treatment Planning
	The Potential Financial Impact of Poor Documentation
	Legal Issues in Documentaton
	Highlights of Chapter 3
	Questions
Chapter 4 Ethical Considerations in Documentation
	Documentation Ethical Principle 1
		Putting It into Practice 4.1
	Documentation Ethical Principle 2
		Putting It into Practice 4.2
	Documentation Ethical Principle 3
		Putting It into Practice 4.3
	Documentation Ethical Principle 4
		Putting It into Practice 4.4
	Documentation Ethical Principle 5
		Putting It into Practice 4.5
	Documentation Ethical Principle 6
		Putting It into Practice 4.6
	Documentation Ethical Principle 7
		Putting It into Practice 4.7
	Highlights of Chapter 4
	Questions
Chapter 5 The Biopsychosocial Assessment
	Conducting the Biopsychosocial Assessment
	Step One: Presenting Problem (Signs and Symptoms)
		Example of Poor Documentation
		Somewhat Better Documentation
		Example of Proper Documentation
	Step Two: History of Present Illness
	Step Three: Client Strengths and Limitations
	Snaps
	The Psychological Report
	Highlights of Chapter 5
	Questions
Chapter 6 The Clinical Interview: Mental Status Exam
	Appearance
	Activity Level
	Speech/Language
	Attitude Toward Examiner
	Affect and Mood
		Range of Affect
		Appropriateness of Affect
		Intensity of Affect
		Mobility of Affect
		Mood
	Stream of Consciousness
		Flight of Ideas
		Loose Associations
		Thought Content
		Hallucinations
	Sensorium/Cognition
		Orientation × 3
		Attention and Concentration
	Judgment
	Insight
	Highlights of Chapter 6
	Questions
Chapter 7 The Clinical Interview: Validating a Diagnosis
	Essential Symptoms
	Associated Features
	Funcional Distress and Impairments
	Examples of Integrating Diagnosis, Symptoms, and Impairments
		Example 1
		Example 2
	The Rule-In/Rule-Out Process
		Steps of Rule-In/Rule-Out Process
	Limitations of the Diagnostic Interview
	Similar Symptoms Do Not Always Suggest the Same Diagnois or Diagnostic Category
	Misdiagnosis Due to Lack of DSM-5 Diagnostic Criteria
		Box 7.1
		Box 7.2
	Highlights of Chapter 7
	Questions
Chapter 8 Formulating a Treatment Plan
	Computerized Treatment Planning
	Getting Started
	Treatment Plan Development
	Goals and Objectives
	Treament Plan Requirements of Third-Party Payers
	Behavioral Objectives: Measurable and Observable
	Subjective Units of Distress (Suds)
	Varying Beliefs and Procedures
		Assessment
		Treatment
		Discharge
	Validating Change
	Insight-Oriented Therapy and Treatment Planning
	Types of Measurement
	Treatment Strategies
	Treatment Plan Formats
	Common Problems in Vague Treatment Plan Writing
	Focused Treatment Plan Writing
		Step 1: Problem Selection
		Step 2: Problem Definition
		Step 3: Goal Development
		Step 4: Objective Construction
		Step 5: Intervention Strategies
		Step 6: Diagnosis Determination
		Step 7: Client Collaboration in Writing Treatment Plans
	Revised Treatment Plans
	Highlights of Chapter 8
	Questions
Chapter 9 Writing Progress Notes
	Progress notes vs. Psychotherapy notes
	Why write progress notes?
	What constitutes a good progress note?
	What content or topics were discussed in the session?
	How did the session address treatment plan objectives?
	What therapeutic interventions and techniques were employed and how effective are they?
	What clinical observatons (behavioral, affective, etc.) Were made?
	What progress or setbacks occurred?
	What signs and symptoms of the diagnosis are present or no longer present?
	How are treatment plan goals and objectives being met at this time?
	What is the current medical necessity for services?
	What Is Being Done Outside The Session To Increase Effectiven
	What are the client’s current limitatons and strengths?
	Other Items to Address in Progress Notes
	Poorly Written Progress Notes Versus Well-Written Progress Notes
	Scientific Method
	Comparative Statements
	Behavioral Charts
	Progress Note Formats
	Session Data
		SOAP Progress Notes
		DAP Progress Notes
	Assessment
	Plan
	Confidentiality Issues and Progress Notes
	Common Problems with Progress Notes
	Saving Time in Writing Progress Notes
	Word-for-word example of a set of progress notes recently sent to this writer for review: very problematic!
	Highlights of Chapter 9
	Questions
Chapter 10 Documenting the Need for Additional Services
	Highlights of Chapter 10
	Questions
Chapter 11 Documenting Mental Health Treatment Outcomes for Individuals
	Types of Data Commonly Used in Measurement
		Nominal
		Ordinal Data
		Interval and Ratio Data
	Use of Outcome Data
	Highlights of Chapter 11
	Questions
Appendix A Putting It All Together: Documented Chart for Mental Health Services
	Signs and Symptoms
	Review of Records
	History of Present Illness
	Biopsychosocial Assessment
	Mental Status Exam (MSE)
		Clinical Observations
		Stream of Consciousness
		Affect/Mood
		Sensorium/Cognition
	Testing
		Minnesota Multiphasic Personality Inventory-2 (MMPI-2)
		Wechsler Adults Intelligence Scale –IV (WAIS-IV)
		TrailMaking A & B
	Summary and Diagnosis
Appendix B Overview of HIPAA Guidelines in Mental Health Sett
	Disclosure of Information
Appendix C Example of Corrective Actions Due to a Therapist’s Poor Documentation
Appendix D Documenting Suicidality
	Authors’ Point of View
	Suggestions for Evaluating Suicidality
	Dealing with the Aftermath of a Suicide
	Conclusion
Glossary
References and Suggested Readings
Index
EULA