"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
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.
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
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
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"!
Hundreds of thousands of students and early-career professionals have relied on this authoritative report-writing tool, now updated for DSM-5/ICD-10-CM and newer types of evaluations. In a convenient 8" x 10.5" format, the book covers nearly all areas of concern addressed in intakes, evaluations, treatment plans, progress notes, and closing summaries. The user seeking the right wording for a clinical document can skim and select from thousands of technical terms, behavioral descriptors, and standard statements. Also provided are interview questions for almost every symptomatic behavior, a huge collection of mental status questions, a reproducible Mental Status Evaluation summary form, and links to hundreds of internet resources. The companion website offers all the URLs from the book, the reproducible forms, and a handy reference on current psychiatric medications. New to This Edition *A list of all psychiatric ICD-10 diagnoses (all of the codes in DSM-5, plus many more), including Z codes essential to a comprehensive biopsychosocial evaluation. *Sample evaluation report keyed to the book's chapters. *Sections on additional clinical issues: intimate partner violence, gender identity, human trafficking, recovery-oriented language, and more. *Many more Internet links, including a wide variety of screening and assessment tools. See also The Paper Office for the Digital Age, Fifth Edition, by Edward L. Zuckerman and Keely Kolmes, which provides the essential record-keeping and risk-reduction tools that every psychotherapy practice needs.
To become and be known as a competent clinician, one must learn all components of good clinical practice. Treatment Planning is an area that is not quite taught in schools yet every organization and clinical level of care would expect a counselor to produce a treatment plan for every client they are billing for. Treatment Planning Made Simple not only gives an outline and strategies for a great structured plan but also offers clinical tools, supervision case consultations, and therapist self care tips. To get more tips to bettering your progress notes or improving your clinical practice, check out my other booklets: Progress Notes Made Simple and the Goal Chaser's Guide to Clinical Practice.