The Psychotherapy Documentation Primer
by Donald E. Wiger
4th Edition
Publisher: John Wiley & Sons P&T
Book Details
| Print ISBN | 9781119709848 |
| eText ISBN | 9781119709930 |
| Publisher | John Wiley & Sons P&T |
| Publishing Year | 2020 |
| Edition | 4th Edition |
| Language | English |
| Pages | 288 |
The Psychotherapy Documentation Primer, 4th Edition, provides structured instruction in clinical record keeping for students and mental health professionals. The textbook addresses documentation practices across the full course of psychotherapy, beginning with the initial interview and continuing through discharge.
Author Donald E. Wiger explains how clinical documentation satisfies standards set by third-party insurers, regulatory agencies, licensing boards, and federal HIPAA regulations. The 2020 edition incorporates diagnostic criteria from the DSM-5 and offers numerous illustrative examples.
The volume emphasizes succinct, empirical recording methods designed to supply clear evidence of treatment effects while reducing time spent on administrative paperwork.
Table of Contents
Chapter 1: Introduction
Chapter 2: The Art and Science of Psychological Assessment and Treatment
Chapter 3: Overview of Current Documentation Procedures and Third-Party Requirements
Chapter 4: Ethical Considerations in Documentation
Chapter 5: The Biopsychosocial Assessment
Chapter 6: The Clinical Interview: Mental Status Exam
Chapter 7: The Clinical Interview: Validating a Diagnosis
Chapter 8: Formulating a Treatment Plan
Chapter 9: Writing Progress Notes
Chapter 10: Documenting the Need for Additional Services
Chapter 11: Documenting Mental Health Treatment Outcomes for Individuals
Chapter Appendix A: Putting it all Together: Documented Chart for Mental Health Services
Chapter Appendix B: Overview of HIPAA Guidelines in Mental Health Settings
Chapter Appendix C: Example of Corrective Actions Due to a Therapist’s Poor Documentation
Chapter Appendix D: Documenting Suicidality
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