The 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 ix

Introduction xi

Chapter 1 Administrative and Intake Forms 1

Introduction

Form 1 Screening Information 6

Form 2 Notice of Appointment 7

Form 3 Consent to Treatment and Recipient’s Rights 8

Form 4 Recipient’s Rights Notification 9

Form 5 Financial Policy 11

Form 6 Payment Contract for Services 12

Form 7 Code of Ethics and Mission Statement 14

Form 8 Therapist’s Ethics Statement 15

Form 9 Agreement Regarding Minors 16

Form 10 Preauthorization for Health Care 18

Form 11 Confidentiality Agreement 19

Chapter 2 Forms Designed for HIPAA Compliance 21

Introduction

Form 12 Privacy of Information Policies 27

Form 13 Request to Amend Health Records 30

Form 14 Request for Restricted Use/Disclosure of Records 31

Form 15 Request for Alternative Means of Confidential Information 32

Form 16 Release of Information Consent 33

Form 17 Record of Requests for Client Information 34

Form 18 Request for Listing of Disclosures of Client Records 35

Chapter 3 Screening Information 37

Form 19 Mental Health Screening Form 38

Form 20 Substance Abuse Screening Form 39

Form 21 Adaptive Functioning Screening Form 40

Form 22 Learning Disability Screening Form 41

Form 23 ADHD Screening Form 42

Chapter 4 Assessment Forms 43

Introduction

Form 24 Initial Assessment—Adult 50

Form 24A Example of Completed Form 58

Form 25 Initial Assessment—Children and Adolescents (<18) 66

Form 25A Example of Completed Form 74

Form 26 Personal History—Adult (18+) 82

Form 26A Example of Completed Form 90

Form 27 Personal History—Children and Adolescents (<18) 98

Form 27A Example of Completed Form 106

Form 28 Couple’s Information Form 114

Form 29 Emotional/Behavioral Assessment 120

Form 29A Example of Completed Form 124

Form 30 Emotional/Behavioral Update 128

Form 30A Example of Completed Form 129

Form 31 Diagnostic Assessment Report 130

Form 31A Example of Completed Form 136

Form 32 Diagnostic Assessment—Lower Functioning 141

Form 32A Example of Completed Form 145

Form 33 Biopsychosocial Report 149

Form 33A Example of Completed Form 152

Chapter 5 Psychological Evaluations 155

Introduction

Form 34 Psychological Evaluation—Adult 157

Form 34A Example of Completed Form 171

Form 35 Psychological Evaluation—Children and Adolescents 186

Form 35A Example of Completed Form 200

Form 36 Psychological/Vocational Assessment 214

Form 37 Neuropsychometric Consultation 224

Chapter 6 Treatment Planning Forms and Procedures 231

Introduction

Form 38 Individual Treatment Plan 236

Form 38A Example of a Poor Treatment Plan 237

Form 38B Example of Completed Form—Adult 238

Form 38C Example of Completed Form—Children and Adolescents 240

Form 39 Short-Term Therapy Treatment Plan 242

Form 39A Example of Completed Form 243

Form 40 Treatment Review 245

Form 40A Example of Completed form 247

Form 41 Treatment Update 249

Form 41A Example of Completed Form 250

Chapter 7 Progress Notes 251

Introduction

Form 42 Progress Notes 258

Form 42A Example of Poor Progress Notes 259

Form 42B Example of Completed Form—Adult 260

Form 42C Example of Competed Form—Children and Adolescents 261

Form 43 Progress Notes—Outline 262

Form 43A Example of Completed Form 263

Form 44 Group Therapy Progress Notes 264

Form 44A Example of Completed Form 265

Form 45 Psychiatric Medication Management Progress Notes 266

Chapter 8 Other Forms Used during the Course of Treatment 269

Introduction

Form 46 Referral for Mental Health Services 272

Form 47 Informed Consent for Medication 273

Form 48 Suicide Contract 274

Form 49 Cooperating in Child Rearing 275

Form 50 Couple’s Analysis of Target Behaviors 280

Form 50A Example of Completed Form 282

Form 51 Third-Party Prior Authorization Request for Continued Services 284

Form 51A Example of Poor Authorization Request 285

Form 51B Example of Completed Form 286

Chapter 9 Chart Review and Outcomes Documentation 287

Introduction

Form 52 Chart Review 289

Form 53 Utilization Review Committee Guide to Review Charts for Audit 291

Form 54 Utilization Review Committee—Chart Review Summary 295

Form 55 Medical Records Audit Chart 296

Form 56 Statement of Confidentiality for Those Auditing or Reviewing Client Charts 302

Form 57 Outcome Survey for Adults 303

Form 58 Outcome Survey for Children 304

Form 59 Outcome Survey for Families and Relationship 305

Chapter 10 Termination and Aftercare 307

Introduction

Form 60 Discharge Summary 309

Form 60A Example of Completed Form 311

Form 61 Termination Letter 313

Bibliography and Suggested Readings 315

CD-ROM Table of Contents 317

About the CD-ROM 319