The Psychotherapy Documentation Primer (Paperback, 3)

Preface vii

How This Book Came Into Being: A Lesson in Making a Really Bad Negative Into a Really Good Positive ix

1 Introduction 1

2 The Art and Science of Psychological Assessment and Treatment 5

3 Overview of Current Documentation Procedures and Third-Party Requirements 11

4 Ethical Considerations in Documentation 35

5 The Biopsychosocial Assessment 47

6 The Mental Status Exam 81

7 Validating a Diagnosis 95

8 Formulating a Treatment Plan 117

9 Writing Progress Notes 145

10 Documenting the Need for Additional Services 175

Appendix A Putting it All Together: Documented Chart for Mental Health Services 181

Appendix B Overview of Outcome Measures 201

Appendix C Overview of HIPAA Guidelines in Mental Health Settings 207

Glossary 211

References and Suggested Readings 221

Index 225