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The Clinical Child Documentation SourcebookReview - The Clinical Child Documentation Sourcebook
A Comprehensive Collection of Forms and Guidelines for Efficient Record-Keeping in Child Mental Health Practice
by Donald K. Freedheim and Jeremy P. Shapiro
John Wiley & Sons, 1999
Review by Molly Mitchell
Feb 7th 2000 (Volume 4, Issue 6)

This book is one in the Practice Planner Series, which contains many books geared towards various aspects of clinical care, treatment planning and documentation. This particular book is designed for those in child-centred practices and is to used as an aid in being as accountable as current regulations dictate. This sourcebook takes into account the specific needs of working with children that, unfortunately, often mean a lot of extra paperwork.

The book begins with a discussion of the pros and cons in the need for increased documentation. The basics of this argument are quality control, ethics and ease of communication between professional versus the extraordinary amount of time this all takes. Having worked in the American system for a number of years, I know all about the hassles of this level of record-keeping. It is interesting for me to now be in a country (Ireland) that has not introduced this kind of accountability in clinical practice and hear all the arguments for implementing more paperwork. It is a pain to do, but it also goes a long way towards making people more aware of what they are actually doing and how that progress is being accomplished.

Anyway, back to this book, which also provides basic information regarding the various reporting formats that are currently used. This will be helpful for those who have not yet ventured out into the mental health work force, and will be familiar for most of those who are working clinically. The basic gist is to find the format that allows you to record the maximum amount of information in the minimum amount of time.

To this aim, the bulk of the book is samples and examples of documents that can be used in clinical practice. All the forms can be copied and used by the purchasers of the book. They can be modified and personalised and a computer disk containing all the forms displayed in the book is provided to ease this process. The types of forms are broken down into the following categories: Administrative Issues and Documents, Intake and Assessment, Diagnostic Evaluation, Consultation and Referral, Treatment Plans, Notes and Summaries (with examples for private practice, hospital work, residential and day treatment programs), and Child Abuse Forms. This is all followed by a case example of how the forms might actually be used in practice.

The Clinical Child Documentation Sourcebook is very thorough and I would hope that no one would ever have to use all the forms explained here. They are certainly helpful, whether to use verbatim, or as a reminder of the issues that need to be dealt with in today’s practices. So, whether you use the forms as they are, or as guidelines, this book would be very valuable in setting up a child practice in any setting.
 

Molly Mitchell is an American psychologist now living and working in Ireland. As a therapist she started out with a degree in Expressive Therapy and then went on to obtain her doctorate in Clinical Psychology. Her particular interest is in working with children and adolescents.

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