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50 Signs of Mental IllnessA Beautiful MindA Beautiful MindA Bright Red ScreamA Casebook of Ethical Challenges in NeuropsychologyA Corner Of The UniverseA Lethal InheritanceA Mood ApartA Research Agenda for DSM-VA Slant of SunA War of NervesAbnormal Psychology in ContextADD-Friendly Ways to Organize Your LifeAddiction Recovery ToolsAdvance Directives in Mental HealthAggression and Antisocial Behavior in Children and AdolescentsAl-JununAlmost a PsychopathAlterations of ConsciousnessAm I Okay?American ManiaAmerican Psychiatric Publishing Textbook of Neuropsychiatry and Clinical NeurosciencesAn American ObsessionAngelheadAnger, Madness, and the DaimonicAnthology of a Crazy LadyApproaching NeverlandAs Nature Made HimAsylumAttention-Deficit Hyperactivity DisorderAttention-Deficit/Hyperactivity DisorderBeing Mentally Ill: A Sociological Theory Betrayal TraumaBetrayed as BoysBetter Than ProzacBetter Than WellBeyond AppearanceBeyond ReasonBinge No MoreBiological UnhappinessBipolar 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Death of PsychotherapyThe Depression WorkbookThe Difficult-to-Treat Psychiatric PatientThe Early Stages of SchizophreniaThe Employee Assistance Treatment PlannerThe Employee Assistance Treatment PlannerThe Epidemiology of SchizophreniaThe Essential Family Guide to Borderline Personality DisorderThe Essentials of New York Mental Health LawThe Ethical WayThe Evolution of Mental Health LawThe Explosive ChildThe Fall Of An IconThe Fasting GirlThe Forensic Documentation SourcebookThe Forgotten MournersThe Gift of Adult ADDThe Good EaterThe Green ParrotThe Healing Power of PetsThe Heart of AddictionThe Heroic ClientThe Insanity OffenseThe Invisible PlagueThe Last Time I Wore a DressThe Limits of Autobiography The LobotomistThe Madness of Our LivesThe Mark of ShameThe Meaning of AddictionThe Meaning of MindThe Medical AdvisorThe Mind/Mood Pill BookThe Most Solitary of AfflictionsThe Mozart EffectThe Naked Lady Who Stood on Her HeadThe Older Adult Psychotherapy Treatment PlannerThe OutsiderThe 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Related Topics
The Clinical Documentation SourcebookReview - The Clinical Documentation Sourcebook
A Comprehensive Collection of Mental Health Practice Forms, Handouts, and Records (Second Edition)
by Donald E. Wiger
John Wiley & Sons, 1999
Review by Kelly Lemmon-Kishi
Jun 14th 1999 (Volume 3, Issue 24)

Smart Paperwork

The Clinical Documentation Sourcebook delivers exactly what it promises on the cover - ready to use forms for managing every stage of the treatment process - "all the forms … and records a mental health professional needs to meet the documentation requirements of the managed care era". You may also learn to respect (if not exactly love) your paperwork, thanks to Wiger's concise explanations. Reminders of the purpose and logic behind each form help - but time saving form design and techniques as well as tips for improved managed care savvy make this book a worthy investment for organizations and private practices. The perfectly formatted, easy to use disk is the icing on the cake - another time saver (but only for those using Windows).

However, there are some major typos! "Liability" instead of "lability," and "fool intolerance" for "food intolerance",…. PROOF READ VERY CAREFULLY before using these documents.

Each chapter begins with a brief explanation and rationale for each form. The author's positive position on the importance of paperwork can help reframe chores into useful tools that work for you, the clinician, as well as 3rd party payers and regulators - and can ultimately benefit your clients. The author notes which forms specifically meet JCAHO requirements. Useful suggestions will also help clinicians avoid some fairly common types of unintentional insurance fraud and potential violations of confidentiality as well as increase success rates in obtaining Prior Authorization from 3rd party payers. Samples of completed forms demonstrate good and bad approaches to paperwork.

Chapter 1 contains intake and termination forms and procedures, including initial client intake form, financial policy statement, payment contract for services, limits of confidentiality form, credit card authorization, release of information consent form, suicide prevention contract, discharge summary form, and a sample termination letter. All of the forms that clients fill out are relatively easy to understand (high school reading level); they are designed to make all aspects of the financial and legal relationship between clinic and client as clear as possible so they are rather long. I particularly like the "limits of confidentiality form" - it is clear, comprehensive, jargon-free and explains the limits of confidentiality thoroughly - but it takes 2 pages!

Chapter 2 contains a series of assessment forms and some assistance in determining which forms are appropriate for which situations. Initial assessment forms, biographical information forms, and personal history forms for both adults and children are included. In addition there are forms for emotional/behavioral assessments, emotional/behavioral updates, biopsychosocial reports, diagnostic assessment reports, and diagnostic assessments for lower functioning clients.

Chapter 3 contains complete forms for performing adult and child psychological evaluations - but no directions. The author refers those unfamiliar with the intricacies of psych-evaluations to his Psychotherapy Documentation Primer (Wiger, 1999, also published by Wiley).

Treatment planning is dealt with in Chapter 4. After two pages outlining the process for developing effective (for client, for agency, for reimbursement) are forms for standard individual and short term therapy treatment planning. These are followed up with treatment review and update forms.

Chapter 5 covers progress notes and prior authorization requests. Wiger's system leads to excellent progress notes that can be done quickly during the session. The form for group therapy progress notes is notable for speed and ease of use, comprehensiveness, good organization, and protection of each client's confidentiality. The sample clinical outcomes questionnaire (to assess consumer satisfaction) and chart review forms (to assess clinician's record keeping) will provide valuable information. The chart review form allows for objective quantifiable assessment of the quality of a client's records that should help make chart reviews constructive learning experiences.

The final chapter includes comprehensive information gathering forms for married and unmarried couples and three good handouts/exercises for couples. Both of the couples information forms are 5 pages and cover much of the same information: current situation, children, areas of satisfaction/dissatisfaction, expectations, allocation of household responsibilities, argument style and responses, and a confidentiality waiver so that the information can be shared during joint sessions. Clients fill out the forms. There are again a few serious typos, though, such as forgetting to change the word "marriage" to "relationship," so proof read these forms carefully before handing them to clients.

The book cover exaggerates when it promises "all the forms, handouts, and records a mental health professional needs…" All is forgiven, though, because all three handouts for couples are excellent. "Cooperating in Child Rearing" is two pages of information, suggestions, and directions followed by three pages of questions; it is very thorough and leads clients through the process of beginning to analyze how their childhood experiences influence their current parenting instincts as well as encouraging cooperation. "Sharing your feelings" is a sentence completion task to jump start emotional sharing, listening, and empathy. The "analysis of target behaviors" asks partners to track problematic behaviors, then analyze the cause, resulting feelings, and "what positive actions could have been taken" to change the outcome.

This is a nice collection, but it needs better proofreading. Thank goodness for the disk!
 


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