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.