Smart Paperwork

The Clinical Documentation Sourcebook delivers exactly what it promises on the cover – ready to use forms for managing every stage of the treatment process – “all the forms … and records a mental health professional needs to meet the documentation requirements of the managed care era”. You may also learn to respect (if not exactly love) your paperwork, thanks to Wiger’s concise explanations. Reminders of the purpose and logic behind each form help – but time saving form design and techniques as well as tips for improved managed care savvy make this book a worthy investment for organizations and private practices. The perfectly formatted, easy to use disk is the icing on the cake – another time saver (but only for those using Windows).

However, there are some major typos! “Liability” instead of “lability,” and “fool intolerance” for “food intolerance”,…. PROOF READ VERY CAREFULLY before using these documents.

Each chapter begins with a brief explanation and rationale for each form. The author’s positive position on the importance of paperwork can help reframe chores into useful tools that work for you, the clinician, as well as 3^rd party payers and regulators – and can ultimately benefit your clients. The author notes which forms specifically meet JCAHO requirements. Useful suggestions will also help clinicians avoid some fairly common types of unintentional insurance fraud and potential violations of confidentiality as well as increase success rates in obtaining Prior Authorization from 3^rd party payers. Samples of completed forms demonstrate good and bad approaches to paperwork.

Chapter 1 contains intake and termination forms and procedures, including initial client intake form, financial policy statement, payment contract for services, limits of confidentiality form, credit card authorization, release of information consent form, suicide prevention contract, discharge summary form, and a sample termination letter. All of the forms that clients fill out are relatively easy to understand (high school reading level); they are designed to make all aspects of the financial and legal relationship between clinic and client as clear as possible so they are rather long. I particularly like the “limits of confidentiality form” – it is clear, comprehensive, jargon-free and explains the limits of confidentiality thoroughly – but it takes 2 pages!

Chapter 2 contains a series of assessment forms and some assistance in determining which forms are appropriate for which situations. Initial assessment forms, biographical information forms, and personal history forms for both adults and children are included. In addition there are forms for emotional/behavioral assessments, emotional/behavioral updates, biopsychosocial reports, diagnostic assessment reports, and diagnostic assessments for lower functioning clients.

Chapter 3 contains complete forms for performing adult and child psychological evaluations – but no directions. The author refers those unfamiliar with the intricacies of psych-evaluations to his Psychotherapy Documentation Primer (Wiger, 1999, also published by Wiley).