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The Clinical Documentation Sourcebook

The Clinical Documentation Sourcebook
Author: Donald E. Wiger
Publisher: John Wiley & Sons
Total Pages: 338
Release: 2010-02-02
Genre: Psychology
ISBN: 0470527781
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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.

The Clinical Documentation Sourcebook

The Clinical Documentation Sourcebook
Author: Donald E. Wiger
Publisher:
Total Pages: 260
Release: 1997-05-05
Genre: Medical
ISBN:
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Accompanying floppy disk contains ... "24 ready-to-use sample forms that meet the documentation requirements of virtually every managed care organization."--Page 4 of cover.

The Continuum of Care Clinical Documentation Sourcebook

The Continuum of Care Clinical Documentation Sourcebook
Author: Chris E. Stout
Publisher: Wiley-Interscience
Total Pages: 306
Release: 1999-11-17
Genre: Medical
ISBN:
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All the forms, handouts, and records you need to meet the paperwork requirements of the managed care era In an era of third-party accountability, your professional survival could hinge on your ability to comply with the documentation requirements of insurers and regulatory agencies. Written by an experienced clinician who has trained thousands of mental health professionals in effective clinical documentation, this sourcebook helps you minimize the potential for billing disputes–or worse–by arming you with the full retinue of required forms, checklists, and records. An indispensable resource for mental health professionals working in inpatient, partial hospitalization, day treatment, and/or residential treatment programs, The Continuum of Care Clinical Documentation Sourcebook is the only book that brings together sample documents covering all stages of treatment–from intake and admission to outcome assessment. Ready-to-use blank forms, handouts, and records make it easy to satisfy the paperwork demands of HMOs, insurers, and regulatory agencies Completed copies of forms illustrate the exact type of information required Clear, concise explanations of the purpose of each form–including when it should be used, with whom, and at what point Forms may be copied from the book or customized on the included disk

The Psychotherapy Documentation Primer

The Psychotherapy Documentation Primer
Author: Donald E. Wiger
Publisher: John Wiley & Sons
Total Pages: 8
Release: 2005
Genre: Medical
ISBN: 0471730165
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"...Records must be kept for managed care reimbursement; for accreditation agencies; for protection in the event of lawsuits; to meet federal HIPAA regulations; and to help streamline patient care in larger practice groups, inpatient facilities, and hospitals...second edition provides the latest information on record keeping for intake, assessment, treatment planning, progress notes, and other essential areas..."--back cover.

The Couple and Family Clinical Documentation Sourcebook

The Couple and Family Clinical Documentation Sourcebook
Author: Terence Patterson, Ph.D.
Publisher:
Total Pages: 180
Release: 1999-02-04
Genre: Psychology
ISBN:
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All of the forms, inventories, checklists, client handouts, and clinical records essential to building and running a successful practice. Has the paperwork monster created by today's managed care environment crippled your couple and family practice? This handy sourcebook—the first in this discipline—is the timesaving resource you've been looking for. It provides couple and family therapists with a full arsenal of tools for assessing and treating clients' problems, and managing today's complicated practices. Providing ready-to-copy blank forms, examples of fully completed forms, and a floppy disk containing all of the blank forms in ready-to-use word-processing files, this invaluable resource will assist you in effectively and efficiently providing services. With The Couple and Family Clinical Documentation Sourcebook you'll spend less time on paperwork and more time with clients. All of the forms, inventories, checklists, client handouts, clinical records, and guidelines essential to building and running a successful practice Ready-to-use blank forms and handouts make it easy to satisfy the paperwork demands of HMOs, insurers, and regulatory agencies Completed copies of forms illustrate the exact type of information required Clear, concise explanations of the purpose of each form—including when it should be used, with whom, and at what point Forms may be copied from the book or customized on the included disk.

The Clinical Child Documentation Sourcebook

The Clinical Child Documentation Sourcebook
Author: Donald K. Freedheim
Publisher:
Total Pages: 276
Release: 1999-02-08
Genre: Psychology
ISBN:
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All the forms, checklists, handouts, and clinical records needed to run a successful child mental health practice The paperwork required when providing mental health services in the current era of third-party accountability continues to mount. This easy-to-use resource offers child psychologists and therapists a full array of forms, inventories, checklists, client handouts, and clinical records essential to a successful practice in either an organizational or clinical setting. From intake to diagnosis and treatment through discharge and outcomes assessment, The Clinical Child Documentation Sourcebook offers sample forms for every stage of the treatment process. Like its bestselling predecessor, The Clinical Documentation Sourcebook, The Clinical Child Documentation Sourcebook includes ready-to-copy blank forms, as well as examples of fully completed forms, and a 3.5" disk that contains word-processing versions of every form in the book. With The Clinical Child Documentation Sourcebook you'll spend less time on paperwork and more time with clients. Ready-to-use blank forms, handouts, and records make it easy to satisfy the paperwork demands of HMOs, insurers, and regulatory agencies Completed copies of forms illustrate the exact type of information required Clear, concise explanations of the purpose of each form—including when it should be used, with whom, and at what point Forms may be copied from the book or customized on the disk included using any DOS or Windows-based word-processing program

The Clinical Documentation Improvement Specialist's Handbook, Second Edition

The Clinical Documentation Improvement Specialist's Handbook, Second Edition
Author: Heather Taillon
Publisher: HC Pro, Inc.
Total Pages: 171
Release: 2011-01-21
Genre: Medical
ISBN: 1601467753
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The Clinical Documentation Improvement Specialist's Handbook, Second Edition Marion Kruse, MBA, RN; Heather Taillon, RHIA, CCDS Get the guidance you need to make your CDI program the best there is... The Clinical Documentation Improvement Specialist's Handbook, Second Edition, is an all-inclusive reference to help readers implement a comprehensive clinical documentation improvement (CDI) program with in-depth information on all the essential responsibilities of the CDI specialist. This edition helps CDI professionals incorporate the latest industry guidance and professional best practices to enhance their programs. Co-authors Heather Taillon, RHIA, and Marion Kruse, MBA, RN, combine their CDI and coding expertise to explain the intricacies of CDI program development and outline the structure of a comprehensive, multi-disciplinary program. In this edition you will learn how to: Adhere to the latest government and regulatory initiatives as they relate to documentation integrity Prepare for successful ICD-10 transition by analyzing your CDI program Step up physician buy-in with the improved education techniques Incorporate the latest physician query guidance from the American Health Information Management Association (AHIMA) Table of Contents Chapter 1: Building the CDI Program Chapter 2: CDI and the healthcare system Chapter 3: Application of coding guidelines Chapter 4: Compliant physician queries Chapter 5: Providing physician education Chapter 6: Monitoring the CDI program What's new in the Second Edition? Analysis of new industry guidance, including: AHIMA's "Managing an Effective Query Process" and "Guidance for Clinical Documentation Improvement Programs." CMS guidance from new IPPS regulations, MLN Matters articles, Quality Improvement Organizations, and the Recovery Audit Contractor (RAC) program, among others Strategies to help you incorporate the guidance into your CDI program. Tools to help you interpret MAC initiatives and RAC focus areas to enhance your CDI program and help prevent audit takebacks New sample queries, forms, tools, and industry survey data BONUS TOOLS! This book also includes bonus online tools you can put to use immediately! Sample query forms Sample job descriptions for CDI managers, and CDI specialists Sample evaluation form for CDI staff Sample pocket guide of common documentation standards

Guide to Clinical Documentation

Guide to Clinical Documentation
Author: Debra D Sullivan
Publisher: F.A. Davis
Total Pages: 416
Release: 2018-07-25
Genre: Medical
ISBN: 0803669992
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Understand the when, why, and how! Here’s your guide to developing the skills you need to master the increasing complex challenges of documenting patient care. Step by step, a straightforward ‘how-to’ approach teaches you how to write SOAP notes, document patient care in office and hospital settings, and write prescriptions. You’ll find a wealth of examples, exercises, and instructions that make every point clear and easy to understand.

Clinical Documentation Reference Guide - First Edition

Clinical Documentation Reference Guide - First Edition
Author: AAPC
Publisher: AAPC
Total Pages: 13
Release: 2020-03-12
Genre: Medical
ISBN: 1626889791
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It's not the quantity of clinical documentation that matters—it's the quality. Is your clinical documentation improvement (CDI) program identifying your outliers? Does your documentation capture the level of ICD-10 coding specificity required to achieve optimal reimbursement? Are you clear on how to fix your coding and documentation shortfalls? Providing the most complete and accurate coding of diagnoses and site-specific procedures will vastly improve your practice’s bottom line. Get the help you need with the Clinical Documentation Reference Guide. This start-to-finish CDI primer covers medical necessity, joint/shared visits, incident-to billing, preventative care visits, the global surgical package, complications and comorbidities, and CDI for EMRs. Learn the all-important steps to ensure your records capture what your physicians perform during each encounter. Benefit from methods to effectively communicate CDI concerns and protocols to your providers. Leverage the practical and effective guidance in AAPC’s Clinical Documentation Reference Guide to triumph over your toughest documentation challenges. Prevent documentation deficiencies and keep your claims on track for optimal reimbursement: Understand the legal aspects of documentation Anticipate and avoid documentation trouble spots Keep compliance issues at bay Learn proactive measures to eliminate documentation problems Work the coding mantra—specificity, specificity, specificity Avoid common documentation errors identified by CERT and RACs Know the facts about EMR templates—and the pitfalls of auto-populate features Master documentation in the EMR with guidelines and tips Conquer CDI time-based coding for E/M The Clinical Documentation Reference Guide is approved for use during the CDEO® certification exam.