The Psychotherapy Documentation Primer
Donald E. Wiger
This Primer offers mental health professionals and students basic
training in clinical record-keeping. It explains the rationale behind, and
the most efficient approach to, the paperwork required when providing mental
health services in the managed care era. This text covers every stage of
the treatment process:
· Biopsychosocial Assessment
· The Mental Status Exam
· Validating a Diagnosis
· The Psychological Report
· Treatment Planning
· Progress Notes
· Documenting the Need for Additional Services
Table of Contents
Overview of Current Documentation Procedures and Third-Party Requirements.
The Biopsychosocial Assessment.
The Mental Status Exam.
Validating a Diagnosis.
Documenting the Need for Additional Services.
Bibliography and Suggested Readings.
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