Clinical Documentation Sourcebook

DONALD E. WIGER, PHD, a psychologist, is director of a mental health clinic in St. Paul, Minnesota. He has taught graduate psychology students for twenty years and provided training seminars to thousands of mental health professionals throughout the United States. He is the author of numerous books, including The Psychotherapy Documentation Primer, Second Edition, also from Wiley.

• Preface to the Fourth Edition ixIntroduction xiChapter 1 Administrative and Intake Forms 1IntroductionForm 1 Screening Information 6Form 2 Notice of Appointment 7Form 3 Consent to Treatment and Recipient’s Rights 8Form 4 Recipient’s Rights Notification 9Form 5 Financial Policy 11Form 6 Payment Contract for Services 12Form 7 Code of Ethics and Mission Statement 14Form 8 Therapist’s Ethics Statement 15Form 9 Agreement Regarding Minors 16Form 10 Preauthorization for Health Care 18Form 11 Confidentiality Agreement 19Chapter 2 Forms Designed for HIPAA Compliance 21IntroductionForm 12 Privacy of Information Policies 27Form 13 Request to Amend Health Records 30Form 14 Request for Restricted Use/Disclosure of Records 31Form 15 Request for Alternative Means of Confidential Information 32Form 16 Release of Information Consent 33Form 17 Record of Requests for Client Information 34Form 18 Request for Listing of Disclosures of Client Records 35Chapter 3 Screening Information 37Form 19 Mental Health Screening Form 38Form 20 Substance Abuse Screening Form 39Form 21 Adaptive Functioning Screening Form 40Form 22 Learning Disability Screening Form 41Form 23 ADHD Screening Form 42Chapter 4 Assessment Forms 43IntroductionForm 24 Initial Assessment—Adult 50Form 24A Example of Completed Form 58Form 25 Initial Assessment—Children and Adolescents (<18) 66Form 25A Example of Completed Form 74Form 26 Personal History—Adult (18+) 82Form 26A Example of Completed Form 90Form 27 Personal History—Children and Adolescents (<18) 98Form 27A Example of Completed Form 106Form 28 Couple’s Information Form 114Form 29 Emotional/Behavioral Assessment 120Form 29A Example of Completed Form 124Form 30 Emotional/Behavioral Update 128Form 30A Example of Completed Form 129Form 31 Diagnostic Assessment Report 130Form 31A Example of Completed Form 136Form 32 Diagnostic Assessment—Lower Functioning 141Form 32A Example of Completed Form 145Form 33 Biopsychosocial Report 149Form 33A Example of Completed Form 152Chapter 5 Psychological Evaluations 155IntroductionForm 34 Psychological Evaluation—Adult 157Form 34A Example of Completed Form 171Form 35 Psychological Evaluation—Children and Adolescents 186Form 35A Example of Completed Form 200Form 36 Psychological/Vocational Assessment 214Form 37 Neuropsychometric Consultation 224Chapter 6 Treatment Planning Forms and Procedures 231IntroductionForm 38 Individual Treatment Plan 236Form 38A Example of a Poor Treatment Plan 237Form 38B Example of Completed Form—Adult 238Form 38C Example of Completed Form—Children and Adolescents 240Form 39 Short-Term Therapy Treatment Plan 242Form 39A Example of Completed Form 243Form 40 Treatment Review 245Form 40A Example of Completed form 247Form 41 Treatment Update 249Form 41A Example of Completed Form 250Chapter 7 Progress Notes 251IntroductionForm 42 Progress Notes 258Form 42A Example of Poor Progress Notes 259Form 42B Example of Completed Form—Adult 260Form 42C Example of Competed Form—Children and Adolescents 261Form 43 Progress Notes—Outline 262Form 43A Example of Completed Form 263Form 44 Group Therapy Progress Notes 264Form 44A Example of Completed Form 265Form 45 Psychiatric Medication Management Progress Notes 266Chapter 8 Other Forms Used during the Course of Treatment 269IntroductionForm 46 Referral for Mental Health Services 272Form 47 Informed Consent for Medication 273Form 48 Suicide Contract 274Form 49 Cooperating in Child Rearing 275Form 50 Couple’s Analysis of Target Behaviors 280Form 50A Example of Completed Form 282Form 51 Third-Party Prior Authorization Request for Continued Services 284Form 51A Example of Poor Authorization Request 285Form 51B Example of Completed Form 286Chapter 9 Chart Review and Outcomes Documentation 287IntroductionForm 52 Chart Review 289Form 53 Utilization Review Committee Guide to Review Charts for Audit 291Form 54 Utilization Review Committee—Chart Review Summary 295Form 55 Medical Records Audit Chart 296Form 56 Statement of Confidentiality for Those Auditing or Reviewing Client Charts 302Form 57 Outcome Survey for Adults 303Form 58 Outcome Survey for Children 304Form 59 Outcome Survey for Families and Relationship 305Chapter 10 Termination and Aftercare 307IntroductionForm 60 Discharge Summary 309Form 60A Example of Completed Form 311Form 61 Termination Letter 313Bibliography and Suggested Readings 315CD-ROM Table of Contents 317About the CD-ROM 319