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The Psychotherapy Documentation Primer, Third Edition
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Table of Contents

Preface vii How This Book Came Into Being: A Lesson in Making a Really Bad Negative Into a Really Good Positive ix 1 Introduction 1 2 The Art and Science of Psychological Assessment and Treatment 5 3 Overview of Current Documentation Procedures and Third-Party Requirements 11 4 Ethical Considerations in Documentation 35 5 The Biopsychosocial Assessment 47 6 The Mental Status Exam 81 7 Validating a Diagnosis 95 8 Formulating a Treatment Plan 117 9 Writing Progress Notes 145 10 Documenting the Need for Additional Services 175 Appendix A Putting it All Together: Documented Chart for Mental Health Services 181 Appendix B Overview of Outcome Measures 201 Appendix C Overview of HIPAA Guidelines in Mental Health Settings 207 Glossary 211 References and Suggested Readings 221 Index 225

About the Author

Donald E. Wiger, PhD, is a practicing psychologist in St. Paul, Minnesota, specializing in conducting psychological evaluations for a variety of purposes. He has taught graduate courses in psychological assessment for over twenty years and has written several texts in the areas of documentation, clinical forms, interviewing, outcomes, and crisis intervention. He conducts seminars nationally in areas such as documentation, interviewing, and private practice.

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