The Psychotherapy Documentation Primer

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Detalles Bibliográficos
Clasificación:Libro Electrónico
Autor principal: Wiger, Donald E.
Formato: Electrónico eBook
Idioma:Inglés
Publicado: Newark : John Wiley & Sons, Incorporated, 2020.
Edición:4th ed.
Temas:
Mental health services > Management.
Mental health services > Medical records.
Psychiatric records.
Services de santé mentale > Gestion.
Services de santé mentale > Dossiers médicaux.
Dossiers psychiatriques.
Mental health services > Management
Mental health services > Medical records
Psychiatric records
Acceso en línea:Texto completo
Tabla de Contenidos:
  • Cover
  • Cover
  • Title Page
  • Copyright Page
  • Contents
  • Preface
  • How This Book Came Into Being: A Lesson in Making a Really Bad Negative Into a Really Good Positive
  • Chapter 1 Introduction
  • Highlights of Chapter 1
  • Questions
  • Chapter 2 The Art and Science of Psychological Assessment and Treatment
  • The Practice of Mental Health as an Art
  • The Practice of Mental Health as a Science
  • Integrating the Art and Science of Mental Health
  • Documentation in the light of art vs. Science
  • Highlights of Chapter 2
  • Questions
  • Chapter 3 Overview of Current Documentation Procedures and Third-Party Requirements
  • Comparing what we "ought to do" to what we were "taught to do"
  • Mental Health Graduate Training
  • Third-Party Payers and Managed Care
  • Medical Necessity
  • Mental Health Criteria
  • Comparison to Documentation in Other Fields
  • Criteria for Clinical Significance
  • The O-F-A-I-D (of aid) Procedure
  • Example of Documentation with O-F-A-I-D Procedure
  • Use of the O-F-A-I-D Procedure in Validating a Diagnosis
  • Functional Impairments
  • Assessment Procedures
  • Integrating Conflicting Observations, Client Statements, Mental Status Exam, Previous Records, and Testing
  • Current Information
  • Psychological Testing
  • Collateral Information
  • Historical Records
  • Treatment Planning
  • The Potential Financial Impact of Poor Documentation
  • Legal Issues in Documentaton
  • Highlights of Chapter 3
  • Questions
  • Chapter 4 Ethical Considerations in Documentation
  • Documentation Ethical Principle 1
  • Putting It into Practice 4.1
  • Documentation Ethical Principle 2
  • Putting It into Practice 4.2
  • Documentation Ethical Principle 3
  • Putting It into Practice 4.3
  • Documentation Ethical Principle 4
  • Putting It into Practice 4.4
  • Documentation Ethical Principle 5
  • Putting It into Practice 4.5
  • Documentation Ethical Principle 6
  • Putting It into Practice 4.6
  • Documentation Ethical Principle 7
  • Putting It into Practice 4.7
  • Highlights of Chapter 4
  • Questions
  • Chapter 5 The Biopsychosocial Assessment
  • Conducting the Biopsychosocial Assessment
  • Step One: Presenting Problem (Signs and Symptoms)
  • Example of Poor Documentation
  • Somewhat Better Documentation
  • Example of Proper Documentation
  • Step Two: History of Present Illness
  • Step Three: Client Strengths and Limitations
  • Snaps
  • The Psychological Report
  • Highlights of Chapter 5
  • Questions
  • Chapter 6 The Clinical Interview: Mental Status Exam
  • Appearance
  • Activity Level
  • Speech/Language
  • Attitude Toward Examiner
  • Affect and Mood
  • Range of Affect
  • Appropriateness of Affect
  • Intensity of Affect
  • Mobility of Affect
  • Mood
  • Stream of Consciousness
  • Flight of Ideas
  • Loose Associations
  • Thought Content
  • Hallucinations
  • Sensorium/Cognition
  • Orientation × 3
  • Attention and Concentration

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