To become and be known as a competent clinician, one must learn all components of good clinical practice. You may be great in some areas and need more supervision is others which is completely normal. One universal mountain to climb is DOCUMENTATION. One who conquers their paperwork conquers their day. Included in this e-book is a handout I created for my supervisees so they can understand the structure of a good note as well as templates that helped me buy back my time. When I bought back my time, I decreased my probability of burn out, and inherited time to work on bettering my clinical practice and become a GOAL CHASER. To gets tips to bettering your clinical practice and accomplishing your professional goals, check out my e-book "Goal Chaser's Guide to Clinical Practice"!
This book provides step-by-step guidelines, tips, and instruction on how to create and write psychotherapy treatment notes. Information and guidance are provided on how to write a treatment intake report, treatment progress notes, and termination summary. A number of sample notes, reports and templates are provided. The book also includes hundreds of representative statements for therapists to use in the design of their own psychotherapy progress notes. A valuable resource for experienced mental health professionals and trainees alike, from the creator of Note Designer therapy note-writing software. ""A time-saving reference to capture the essence and the methods of professional note writing for psychotherapists. Easy to apply and great to keep close-by when writing reports and progress notes."" --Alexandre Smith-Peter, Psy.D. candidate
Dr. Rhonda Sutton's second edition of the straightforward guide to progress notes includes additional examples, information, documentation, and clinical language that expands on the utility and readability of the first book. Additional case studies provide examples of how to use the STEPs to format notes. New chapters include information on clinical language and documentation. This book covers everything about progress notes, from how to write them, to how to store them, and even what to do when someone requests to them. In addition, clinical terms and abbreviations are included as well as suggestions for other clinical documentation such as termination letters, privacy statements, and professional disclosure statements. Suited for all types of mental health clinicians, this book will help therapists improve upon their progress notes and other forms of clinical documentation.
Now with DSM-5 Content! This pocket guide delivers quick access to need-to-know information on basic behavioral theories, key aspects of psychiatric and crisis interventions, mental status assessments and exams, mental health history and assessment tools, and so much more.
All the forms, handouts, and records mental health professionals need to meet documentation requirements–fully revised and updated The paperwork required when providing mental health services continues to mount. Keeping records for managed care reimbursement, accreditation agencies, protection in the event of lawsuits, and to help streamline patient care in solo and group practices, inpatient facilities, and hospitals has become increasingly important. Now fully updated and revised, the Fourth Edition of The Clinical Documentation Sourcebook provides you with a full range of forms, checklists, and clinical records essential for effectively and efficiently managing and protecting your practice. The Fourth Edition offers: Seventy-two ready-to-copy forms appropriate for use with a broad range of clients including children, couples, and families Updated coverage for HIPAA compliance, reflecting the latest The Joint Commission (TJC) and CARF regulations A new chapter covering the most current format on screening information for referral sources Increased coverage of clinical outcomes to support the latest advancements in evidence-based treatment A CD-ROM with all the ready-to-copy forms in Microsoft® Word format, allowing for customization to suit a variety of practices From intake to diagnosis and treatment through discharge and outcome assessment, The Clinical Documentation Sourcebook, Fourth Edition offers sample forms for every stage of the treatment process. Greatly expanded from the Third Edition, the book now includes twenty-six fully completed forms illustrating the proper way to fill them out. Note: CD-ROM/DVD and other supplementary materials are not included as part of eBook file.
Save hours of time-consuming paperwork with the bestselling treatment planning system The Adult Psychotherapy Progress Notes Planner, Fifth Edition contains complete prewritten session and patient presentation descriptions for each behavioral problem in The Complete Adult Psychotherapy Treatment Planner, Fifth Edition. The prewritten progress notes can be easily and quickly adapted to fit a particular client need or treatment situation. Saves you hours of time-consuming paperwork, yet offers the freedom to develop customized progress notes Organized around 43 behaviorally based presenting problems, including depression, intimate relationship conflicts, chronic pain, anxiety, substance abuse, borderline personality, and more Features over 1,000 prewritten progress notes (summarizing patient presentation, themes of session, and treatment delivered) Provides an array of treatment approaches that correspond with the behavioral problems and DSM-5TM diagnostic categories in The Complete Adult Psychotherapy Treatment Planner, Fifth Edition Offers sample progress notes that conform to the requirements of most third-party payors and accrediting agencies, including CARF, The Joint Commission (TJC), COA, and the NCQA Identifies the latest evidence-based care treatments with treatment language following specific guidelines set by managed care and accrediting agencies
Publisher's Note: Products purchased from 3rd Party sellers are not guaranteed by the Publisher for quality, authenticity, or access to any online entitlements included with the product. Feeling unsure about the ins and outs of charting? Grasp the essential basics, with the irreplaceable Nursing Documentation Made Incredibly Easy!®, 5th Edition. Packed with colorful images and clear-as-day guidance, this friendly reference guides you through meeting documentation requirements, working with electronic medical records systems, complying with legal requirements, following care planning guidelines, and more. Whether you are a nursing student or a new or experienced nurse, this on-the-spot study and clinical guide is your ticket to ensuring your charting is timely, accurate, and watertight. Let the experts walk you through up-to-date best practices for nursing documentation, with: NEW and updated, fully illustrated content in quick-read, bulleted format NEWdiscussion of the necessary documentation process outside of charting—informed consent, advanced directives, medication reconciliation Easy-to-retain guidance on using the electronic medical records / electronic health records (EMR/EHR) documentation systems, and required charting and documentation practices Easy-to-read, easy-to-remember content that provides helpful charting examples demonstrating what to document in different patient situations, while addressing the different styles of charting Outlines the Do's and Don’ts of charting – a common sense approach that addresses a wide range of topics, including: Documentation and the nursing process—assessment, nursing diagnosis, planning care/outcomes, implementation, evaluation Documenting the patient’s health history and physical examination The Joint Commission standards for assessment Patient rights and safety Care plan guidelines Enhancing documentation Avoiding legal problems Documenting procedures Documentation practices in a variety of settings—acute care, home healthcare, and long-term care Documenting special situations—release of patient information after death, nonreleasable information, searching for contraband, documenting inappropriate behavior Special features include: Just the facts – a quick summary of each chapter’s content Advice from the experts – seasoned input on vital charting skills, such as interviewing the patient, writing outcome standards, creating top-notch care plans “Nurse Joy” and “Jake” – expert insights on the nursing process and problem-solving That’s a wrap! – a review of the topics covered in that chapter About the Clinical Editor Kate Stout, RN, MSN, is a Post Anesthesia Care Staff Nurse at Dosher Memorial Hospital in Southport, North Carolina.
Written for clinicians this guide provides an easily understood framework in which to set formalised goals, establish treatment objectives and learn diagnostic techniques. Professional forms are included in sample form for insurance purposes.
"This book is a way for counselors to conceptualize their therapy sessions with their clients. The STEPnotes structure aids in the therapeutic process, and provides a professional format for other administrative functions"--Back cover
Provides homework tips, tools, and solutions for parents and their children customized by the child's homework profile: the disorganized, the rusher, the procrastinator, the avoider, the inattentive, and the easily frustrated.
