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Federico Grosso, DDS, PhD, MFT, BCFE
FGrosso.com
805-962-3628

fcgt@fgrosso.com

MENTAL HEALTH RECORDS MADE EASY: A WORKBOOK AND CD FOR MENTAL HEALTH PROFESSIONALS © 5th Edition (2009)

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MENTAL HEALTH RECORDS MADE EASY: A WORKBOOK AND CD FOR MENTAL HEALTH PROFESSIONALS

This book addresses required elements for keeping records that can help defend a clinician when facing legal action. This book discusses the nature of assessment, diagnosis, and treatment and how the clinician is required to document these elements appropriately. However, few books exist that use clarity when presenting an effective and simple model that meets the needs of the clinician. Clinical examples are used to explain how to document the different components. The clinician proceeds to learn about appropriate documentation using the treatment or progress notes. Some clinicians advocate writing everything that transpired in treatment. The author, based on his expert witness in malpractice cases, eschews that approach due to its inherent danger. Instead, the author uses vignettes and examples to teaches the clinician how to write a minimal amount of content yet meeting the needs of the client and clinician. 

Most importantly, this book addresses an inherently challenging and potentially harmful clinical situation: managing the high risk client. These clients potentially have a higher tendency than normal to initiate a lawsuit when the outcome may cause actual or perceived harm to the client. Clinicians are shown how to document all elements of necessary assessment, diagnosis, and treatment to diminish the possibility of facing a malpractice action. The included CD contains the editable form in MS word.

5th Edition, 2009


Table of Contents


Introduction


Chapter 1 Purpose of Mental Health Records


Chapter 2 The Content of Mental Health Records


Intake Form

Informed Consent Form

Ledger Form

Psychometric Testing

5-Axis Diagnosis

Treatment Plan

Prognosis

Consultation and Medical Information

Progress Notes

Discharge Summary


Chapter 3 Sample Clinical Forms


Sample Intake Form

Sample Informed Consent Form

Sample Ledger Form

Sample Mental Status Form

Sample Release of Information Form

Sample Diagnosis, Treatment Plan, and Prognosis Form

Sample Consultation Form

Sample Progress Notes Form

Sample Discharge Form


Chapter 4 Writing Case Notes


Steps to Follow in Writing Case Notes

Documenting Chief Complaint and Scope of Practice

Documenting Diagnosis

Consultations and Referrals

Writing Progress Notes

Challenging Legal and Ethical Issues

Documenting the Confidentiality Bind

Documenting Legal Challenges

Writing Discharge Summaries


Chapter 5 Clinical Examples and Vignettes


Example 1: Documenting Chief Complaint and Scope of Practice

Example 2: Documenting Chief Complaint and Scope of Practice

Example 3: Psychometric Assessment

Example 4: Consultation

Example 5: Progress Notes

Practice Vignettes

Scope of Practice and Presenting Issue Vignettes

Psychometric Assessment Vignettes

Consultation Vignettes

Progress Notes Vignettes

Legal and Ethical Challenges Vignettes


Chapter 6 Appendix


Practice Vignettes

Scope of Practice and Presenting Issue

Psychometric Assessment

Diagnosis and Treatment Planning

Treatment Plan

Progress Notes

Legal and Ethical Challenges

Index

 The forms in the CD are provided in MS Word.