THE ART OF WRITING MENTAL HEALTH RECORDS © 3RD Edition (2011)

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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.

3rd Edition, 2011

Table of Content

Chapter 1 The Purpose of Mental Health Records 9

Vignette 10

Unpredictability in Clinical Practice 11

Unpredictability: A Clinical Example 12

Vignette 14

The Clinician’s Perspective 14

The Client’s Perspective 14

The Clinical Impasse 14

Jason Fails to Protect Himself 15

Chapter 2          The Content of Mental Health Records 17

Essential Protective Documentation 17

Intake Form 18

Informed Consent Form 19

Written Release of Information Form 19

Ledger Form 20

Psychometric Testing 20

5-Axis Diagnosis 22

Treatment Plan 23

Prognosis 24

Consultation and Medical Information 24

Progress Notes 25

Documentation of a High Risk Client Challenge 25

Vignette 26

Legal Documentation for the Previous Vignette 27

Discharge Summary 27

Mental Health Protocol Interaction 28

Chapter 3 Sample Clinical Forms 31

Sample Intake Form 32

Sample Informed Consent Form 33

Sample Ledger Form 37

Sample Mental Status Form 38

Sample Release of Information Form 39

Sample Diagnosis, Treatment Plan, and Prognosis Form 40

Sample Consultation Form 41

Sample Progress Notes Form 42

Sample Discharge Form 43

Chapter 4 Writing Case Notes 45

Imagine the Following Clinical Scenario 45

The Standard of Care for Writing Mental Health Records 45

The Standard of Care for Writing Case Notes 46

Documenting Scope of Practice 47

Scope of Practice Vignette 48

Documenting Chief Complaint or Presenting Issue 48

Chief Complaint or Presenting Issue Vignette 49

Documenting Diagnosis 49

Diagnosis Vignette 50

Consultations and Referrals 51

Consultations Vignette 51

Documenting the Mental Status Exam (MSE) 52

Consider the Following Example 52

Consider the Following Documentation as an Example 54

Documenting the Beck Depression Inventory 54

Beck Depression Inventory Vignette 55

Documenting Treatment Plans 55

Sample Generic Treatment Plan 57

Treatment Plan Vignette 58

Writing Progress Notes 59

Progress Notes Vignette 60

The Integration of Mental Health Records 64

Documenting the Confidentiality Bind 65

Facing Legal and Ethical Challenges 66

Documenting Legal Challenges 68

The Developing Clinical Challenge 69

Preventing Harm to the Client 69

Protecting the Clinician 70

Defining the Protective Steps 70

Vignette A 71

Vignette B 72

Writing Discharge Summaries 73

Sample Discharge Summary 74

Chapter 5 Practice Vignettes 75

Vignette 1: Documenting Chief Complaint and Scope of Practice 75

Vignette 1: Psychometric Assessment 76

Vignette 1: Diagnosis 77

Vignette 1: Treatment Plan 77

Vignette 1: Progress Notes 78

Vignette 1: Discharge Summary 78

Vignette 2: Documenting Chief Complaint and Scope of Practice

for Mrs. Doe 79

Vignette 2: Psychometric Assessment for Mrs. Doe 79

Vignette 2: Consultation for Mrs. Doe 80

Vignette 2: Diagnosis for Mrs. Doe 80

Vignette 2: Treatment Plan for Mrs. Doe 80

Vignette 2: Progress Notes for Mrs. Doe 81

Vignette 2: Documenting Discharge Summary for Mrs. Doe 82

Vignette 2: Documenting Chief Complaint and Scope of Practice

for Mr. Doe 82

Vignette 2: Psychometric Assessment for Mr. Doe 83

Vignette 2: Consultation for Mr. Doe 83

Vignette 2: Diagnosis for Mr. Doe 83

Vignette 2: Treatment Plan for Mr. Doe 84

Vignette 2: Progress Notes for Mr. Doe 84

Vignette 2: Documenting Discharge Summary for Mr. Doe 85

Vignette 3: Documenting Chief Complaint & Scope of Practice 85

Vignette 3: Psychometric Assessment 86

Vignette 3: Consultation 86

Vignette 3: Diagnosis 87

Vignette 3: Treatment Plan 87

Vignette 3: Progress Notes 87

Vignette 3: Documenting Discharge Summary 88

Vignette 4: Documenting Chief Complaint & Scope of Practice 88

Vignette 4: Psychometric Assessment 89

Vignette 4: Consultation 89

Vignette 4: Diagnosis 90

Vignette 4: Treatment Plan 90

Vignette 4: Progress Notes 91

Vignette 4: Documenting Discharge Summary 91

Practice Vignettes 92

Chapter 6 Appendix 97

Practice Vignettes 97

Scope of Practice and Presenting Issue 97

Psychometric Assessment 100

Diagnosis and Treatment Planning 100

Progress Notes 105

Legal and Ethical Challenges 106

Index

The forms in the CD are provided in MS Word.