The Clinical Documentation Sourcebook

The Complete Paperwork Resource for Your Mental Health Practice

Donald E. Wiger

• Publisher: Wiley
• Year: 2009
• Print ISBN:
  9780470527788
• Edition: 4
• eBook ISBN:
  9780470575871
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

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.

CHAPTER 1

Administrative and Intake Forms

THE MENTAL HEALTH CLINIC’S INTAKE INFORMATION forms elicit demographic and payment information about the client. They also communicate business, legal, and ethical issues and responsibilities. Although initial intake forms do not provide specific clinical information, they do provide an understanding of the responsibilities of both the client and the clinic. In each case, these forms are taken care of prior to the first counseling session. All insurance and financial agreements are contracted with the client before services begin. The clinic’s financial policies must be clearly spelled out. In addition, the client should be made aware of, and agree to, the limits of confidentiality in a counseling session.

Common client questions are: “What if my insurance company does not pay?” “How confidential is the session?” “Do parents have the right to their children’s records?” “What happens if payment is not received?” “What happens if suicide is mentioned?” and “What is the price of therapy?” These and other questions are not only answered but also documented and signed. Any of these issues, if not covered, could lead to misunderstanding, subsequent premature termination of treatment, ethics changes, or a lawsuit. Intake forms provide clear communication between the client and clinic, with the aim of eliminating misunderstandings detrimental to the therapeutic process and clinic survival.

FORM 1 Screening Information

The screening information form contains demographic information that is generally held by office personnel for administrative reasons. It is filled out prior to meeting the teenager and is kept separately from the client’s confidential medical records. The information contained is used for ongoing office and billing procedures in which a quick reference is needed without having to access the client’s medical records. It excludes private clinical information and is typically readily accessible to administrative/office/billing personnel. The form also provides emergency contact information as required by accrediting agencies. For example, if a client has a medical problem or becomes suicidal, information such as emergency contacts, the primary physician, and other background information must be readily available. Referral source information may be used for tracking purposes.

FORM 2 Notice of Appointment

This form serves to remind the client of an upcoming initial appointment and instructs the client on what information to bring to the session.

FORM 3 Consent to Treatment and Recipient’s Rights

A statement of consent for treatment and the client’s rights are common requirements of accreditation agencies. The client further acknowledges reading and understanding their rights as a patient. The form further explains various situations in which the client could be discharged from treatment nonvoluntarily and the limits of confidentiality.

FORM 4 Recipient’s Rights Notification

The information contained in this client handout includes disclosures often required by accreditation agencies that inform clients of their rights as consumers of mental health services.

FORM 5 Financial Policy

Clinical skills are necessary but are not the sole component in the overall scope of mental health services. A concise, written financial policy is crucial to the successful operation of any practice. Clear financial policies and procedures eliminate much potential discord (and premature termination of services) between the client and the therapist and clinic. Clinics that thrive financially and are self-sufficient have few accounts receivable at any time. An adequate financial policy statement addresses the following:

• The client is ultimately responsible for payment to the clinic. The clinic cannot guarantee insurance benefits. (Note: Some managed care contracts forbid client payment to the clinic for noncovered services without permission.)

• Clinics that bill insurance companies should convey to clients the fact that billing third-party payers is simply a service—not a responsibility—of the clinic.

• There are time limits in waiting for insurance payments, after which the client must pay the clinic. Some clinics collect the entire amount initially from the client and reimburse the client when insurance money is received.

• The clinic’s policy regarding payment for treatment of minors should be noted.

• The policy regarding payment for charges not covered by third-party payers should be addressed.

• The financial policy form should be signed by the person(s) responsible for payment.

• Assignment of benefit policies should be addressed.

• The financial policy statement should specify when payments are due and policies for nonpayment.

• Methods of payment should be listed.

Request clients to read and sign the financial policy statement (Form 5) prior to the first session. Some mental health providers ask clients to come to the first session 15 to 20 minutes early to review the initial policies and procedures. Take care of all financial understandings with the client before the first session begins; otherwise, valuable session time might be taken up reviewing financial issues.

When this information is unclear or unknown, there is room for misunderstanding between the mental health care provider and the client. Clients usually believe that all services performed in therapy are covered by their insurance. But mental health benefits from several sources are decreasing, and only specific, limited services are now covered. For example, just a few years ago several third-party payers paid for testing; today testing is seldom considered a standard procedure and often needs prior approval. Another trend is that most managed care companies approve only a set number of sessions at a time, while in the past few restrictions were made.

Initial insurance information provided by third-party payers is not a guarantee of benefits. Each mental health care provider should have a clear financial policy and payment contract (possibly on the same form) to explain conditions of payment in the event that the third-party payer denies payment.

FORM 6 Payment Contract for Services

Along with the financial policy statement, the payment contract is vital for the clinic’s financial survival. Without a payment contract, clients are not clearly obligated to pay for mental health services. The payment contract (Form 6) meets federal criteria for a truth in lending disclosure statement for professional services and provides a release of information to bill third parties.

The contract lists professional fees that will be charged. (A clinical hour should be defined by the number of minutes it covers rather than stating “per ...

Table of contents

• Title Page
• Copyright Page
• Dedication
• Preface to the Fourth Edition
• Introduction
• CHAPTER 1 - Administrative and Intake Forms
• CHAPTER 2 - Forms Designed for HIPAA Compliance
• CHAPTER 3 - Screening Information
• CHAPTER 4 - Assessment Forms
• CHAPTER 5 - Psychological Evaluations
• CHAPTER 6 - Treatment Planning Forms and Procedures
• CHAPTER 7 - Progress Notes
• CHAPTER 8 - Other Forms Used during the Course of Treatment
• CHAPTER 9 - Chart Review and Outcomes Documentation
• CHAPTER 10 - Termination and Aftercare
• Bibliography and Suggested Readings
• CD-ROM Table of Contents