The Psychotherapy Documentation Primer (2^nd Edition) is part of Wiley's Practice management series.  The series provides mental health practitioners a wealth of jargon-free, practical, hands-on information to aid in the vicissitudes of clinical practice.  The Psychotherapy Documentation primer is a solid contribution to this series, and fills a needed niche in the field.

The book is broken down into 8 chapters, covering such topics as "biopsychosocial assessment", "mental status exam", "formulating and validating a diagnosis", "treatment planning", "progress notes", and "documenting the need for additional services." The book contains a sample client chart, and appendices with overviews of outcome measures and HIPAA guidelines.  The included client chart has sample progress notes and requests for additional services. Examples of good and bad process notes are scattered throughout the text.

This book is an invaluable reference guide for starting therapists who would like to learn good habits in the standards and practice of record management, as well as seasoned therapists who would like to improve their own client documentation practices.  Given the APA guidelines mandating clear and accurate client records, as well as the importance that such practices play in insurance reimbursement as well as forensic settings, it amazes me how little time is spent explicitly teaching and reinforcing these practices in graduate school settings.  In my own graduate school experience, I do not remember taking a single class where we were taught what to include/exclude in progress notes or clinic reports.  I do remember an ambiguous directive of not including "too much or too little"- too vague a statement to be really informative or helpful.  This book provides an excellent sourcebook to those that have been likewise directed in their own clinical programs, or to those who never attended such programs and want to provide services in an ethical manner. 

Of course the rub with this type of book, and this book certainly falls into this trap, is that many of the directives are almost too basic and obvious.  This is not a negative of the book as I am not sure that being too simple is avoidable given the content and goals of the book. Simple is good in this context.  It makes for a quick, easy read and at worst, it will be a validating experience for clinicians checking on their own work.  At best, it will improve the quality of care for clients who are working with therapists who have not yet recognized the importance of clear case documentation.

© 2007 Michael Sakuma

Micheal J. Sakuma, Ph.D. , Psychology Department, Dowling College

Categories: Psychotherapy