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Tables of Contents for The Paper Office
Chapter/Section Title
Page #
Page Count
List of Figures, Forms, and Handouts
xix
Introduction
1
1
Ways This Book Can Help You
1
1
What This Book Contains
2
1
Unique Features
3
1
How to Use This Book in Your Practice
3
1
Quick Start: Recommended Core Materials
4
1
Availability of Materials on CD-ROM
5
1
A Cautionary Note and Disclaimer
5
1
About Reproducing Materials in This Book
6
1
Your Forms and Other Contributions: A Nice Offer
7
1
Future Developments
7
2
Basic Paperwork and Communication Tools
9
24
Basic Paperwork Tools: An Overview
9
1
Presenting Yourself on Paper
10
6
Ethical Aspects of Self-Presentation
10
1
Guidelines for Clear and Accurate Self-Presentations
11
1
The Name of Your Practice
12
1
Your Stationery and Cards
12
3
Your Resume and Curriculum Vitae
15
1
Your Appointment Book
16
2
Figure 1. Sample curriculum vitae, partially filled in
17
1
What an Appointment Book Should Include
18
1
A List of Current Clients
18
1
Basics of Record Keeping
18
7
Why Keep Records?
19
1
What Should Be in the Records?
20
1
The Physical Structure for Organizing Your Case Records
21
1
Form 1. Checklist for client records
22
3
Record Security
25
1
Retention of Records
26
7
How Long Should Records Be Kept?
26
1
Suggestions on Retaining Records
27
1
Disposal of Your Records
27
1
Preserving Your Records When You Close Your Practice, Retire, or Die
28
5
Financial Tools and Procedures
33
39
Setting Financial Policies for Your Practice
33
8
About Fees
34
1
Ethical Guidelines on Fees
35
1
Setting Your Fee
36
1
Other Fee Arrangements
37
3
Discussing Fees
40
1
Tips on Collecting Fees
41
1
The Income Record
41
2
Figure 2. Sample monthly income record
42
1
The Expense Record I: Your Checkbook
43
1
Choosing a Checking Account
43
1
Guidelines for a Business Checkbook
43
1
Choosing a Credit Card
44
1
The Expense Record II: Monthly/Quarterly Expense Summary
44
2
Form 2. Monthly/quarterly expense summary
45
1
Methods of Billing
46
4
Credit Cards
46
1
Statements
46
1
SuperΨbills
46
1
Computerized Billing Programs
47
1
Billing Services
47
1
A Weekly Summary for Billing
47
1
A Record of Services Provided
48
1
Form 3. Record of services provided
49
1
Collecting Overdue Fees from Clients
50
2
Calling the Client
51
1
Sending a Note on the Bill
51
1
Sending Collection Letters
51
1
Other Methods
51
1
Billing Third Parties---and Getting Reimbursed
52
7
Advice on Procedures for Clients with Health Insurance
52
1
What You Need to Know for Insurance Processing
53
2
Billing for Medicare Patients
55
1
Checklist for Avoiding Illegal and Unethical Billing Procedures
55
2
Late Payments from Insurers
57
1
Authorization of Benefits
58
1
Marketing Your Practice Ethically
59
13
Practice Announcement Letters
60
2
A Referral-for-Psychotherapy Questionnaire
62
1
A Referral Form for Group Therapy
62
1
``Thanks for the Referral'' Notes
62
1
Form 4. Referral-for-psychotherapy questionnaire
63
2
Form 5. Referral form for group therapy
65
3
Sending Progress Notes to the Referrer or Cotreater
68
1
Where Do Your Referrals Come From?
69
2
Collecting Feedback on Your Psychological Reports
71
1
Reducing Malpractice Risk by Operating Ethically
72
100
Ethics and Malpractice
72
4
Why Are Ethical and Legal Issues So Complicated
72
1
The Major Malpractice Risks for Clinicians
73
2
Four Steps toward Ethical Self-Protection
75
1
Legal Aspects of Malpractice
76
4
When Do Patients Sue?
76
1
What Is Malpractice?
76
1
The Good News (for Us): The Real Risks Are Small
77
1
The Bad News (for Us): Malpractice Accusations Hurt
77
1
What to Do If You Are Complained Against: A Checklist
78
2
Professional Liability (``Malpractice'') Insurance
80
14
Introduction
80
1
Occurrence-Based versus Claims-Made Policies
80
1
Figure 3. An illustration of your coverage in claims-made and occurrence-based policies over time
81
2
Points of Comparison and Advantage
83
1
Guidelines and Issues to Consider When Purchasing Liability Insurance
84
5
Checklists for Comparing Professional Liability Insurance Policies
89
4
Other Kinds of Insurance You Might Need
93
1
Ways to Reduce Your Risk of Malpractice
94
9
Twenty-Two Steps for Risk Reduction
94
6
Other Risk Areas for Malpractice
100
1
Risks in Repressed-Memory Therapy
101
2
Evaluating the Ethicality of Proposed Treatments
103
2
Avoiding Malpractice in Psychological Testing
105
4
Require the Client to Give Consent
105
1
Know the Rules
106
1
Stay within Your Areas of Competence
106
1
Administer Tests the Way They Were Designed
107
1
Interpret and Report Your Findings Carefully
107
1
Be Alert for Biasing Factors
107
1
Be Aware of Forensic Issues
108
1
Be Thorough
109
1
Boundary Issues
109
1
Dual (or Multiple) Relationships
109
5
What Are Dual Relationships?
109
1
Why Avoid Dual Relationships?
109
1
Figure 4. Are you in trouble with a client?
110
2
Types of Dual Relationships
112
1
When Dual Relationships Are Not Avoidable: Weighing Their Effect
113
1
Preventing Trouble
114
1
Sexual Intimacies in Therapy
114
15
Handout 1. Patient handout on limits of the therapy relationship
115
1
What Is Meant by ``Sexual Intimacies''?
116
1
With Whom Are Sexual Intimacies Prohibited?
116
1
Who Is Prohibited from Engaging in Intimacies?
117
1
The Damage to the Client and to Therapy
117
1
Negative Consequences to the Clinician
118
1
Not Me! I Would Never!
119
1
Is Sexual Intimacy with a Client Ever Acceptable?
120
2
A Checklist of Preventive Measures
122
1
What to Do If a Client Asks You for Sex
122
1
Consciousness Raising
123
1
What to Do If You Are Attracted to a Client
124
1
Reporting Another Therapist
125
1
Client-Therapist Intimacy: Appropriate and Inappropriate Conduct
125
1
Handout 2. Patient handout on client--therapist contact
126
3
The Duty to Protect (and Warn)
129
4
The Legal Basis
130
1
When Do You Have a ``Duty to Warn''?
130
1
What to Do When You Decide to ``Warn''
131
1
Suicide
132
1
Family Violence and Abuse
132
1
Assessing a Client's Dangerousness to Self and Others
133
10
Prepare Ahead of Time
133
1
Gather Information to Assess Risk
133
1
Evaluate the Risk Factors Present
134
3
Form 6. Checklist of suicide risk factors
137
3
Analyze the Information Gathered
140
1
Document the Situation and Your Actions
141
1
Manage the Risk
141
2
Do Damage Control
143
1
Limit Your Personal Vulnerability to Violence
143
1
Ethical and Legal Issues in Working with Managed Care Organizations
143
20
Conflicts and Concerns
144
1
Joining an MCO Panel
144
1
Complexities in Your Contract with the MCO
145
1
Beginning to See MCO Clients
146
1
Initial Discussions with the Client about MCO-Related Ethical Issues
147
2
Verification of Coverage
149
1
Form 7. Behavioral health insurance benefits questionnaire
150
3
Dealing with MCO Reviewers
153
1
Continuity of Care Concerns
154
1
Educating Clients about Managed Care
155
1
Handout 3. Patient handout for education about/informed consent to managed care
156
2
The Concept of ``Medically Necessary'' Care
158
1
Coping with Administrative Burden, Fees, and Payments
158
1
Form 8. Medical-necessity-for-psychotherapy checklist
159
1
What Can a Clinician Do?
160
3
Legal and Ethical Aspects of Supervising and Being Supervised
163
9
Risks and Responses
163
2
A Formal Agreement
165
1
A Record of Supervision Meetings
165
1
Form 9. Agreement for professional supervision
166
4
Consulting
170
1
Resources for Supervision and Consultation
171
1
Getting Informed Consent
172
73
The What and Why of Getting Informed Consent
172
8
What Informed Consent Requires
172
5
The Three Steps to Obtaining Informed Consent
177
1
Do Written Consent Forms Have a Negative Effect on Clients or Treatment?
178
1
The Five Paths to Informed Consent
179
1
The First Path to Informed Consent: The Client Information Brochure
180
26
Kinds of Brochures
180
1
How to Use the Model Client Information Brochure
181
1
The Model Client Information Brochure
182
24
The Second Path to Informed Consent: The Question List as a Guide to Discussion
206
5
The Third Path to Informed Consent: List of Clients' Rights
211
3
Handout 4. Question list for therapist-client discussion (client's version)
212
2
About Handouts 5, 6, and 7
214
1
The Fourth Path to Informed Consent: Psychotherapy Contracts
214
18
The Nature of Contracts
214
1
Handout 5. First clients' rights form
215
1
Handout 6. Second clients' rights form
216
1
Handout 7. Third clients' rights form
217
1
Checklists for a Psychotherapy Contract: Elements and Options
218
3
A Contract for Individual Therapy with an Adult
221
1
Form 10. Contract for Individual adult therapy
222
1
About Contracts for Couples and Families
223
1
Contracts for Therapy with Minors
224
2
Form 11. Contract with parent/guardian for psychotherapy with a minor
226
1
Form 12. Contract for psychotherapy with an older child or adolescent
227
1
A Contract for Group Therapy
228
1
Form 13. Contract for group therapy
229
3
The Fifth Path to Informed Consent: Consent to Treatment and Other Services
232
13
Generic Consent to an Adult's Treatment
232
1
Generic Consent to a Minor Child's Treatment
232
1
Form 14. Form for generic consent to treatment of an adult
233
1
Form 15. Form for generic consent to treatment of a child
234
1
Consent to Counseling for a Child of Divorce
235
1
Authorization to Record Sessions and Use Case Materials
235
1
Form 16. Agreement for parents regarding limitations and goal of psychotherapy with a child of divorce
236
2
Form 17. Release/permission form for recording sessions and using case materials in research, teaching, and professional publishing
238
3
Consent to Psychological Testing
241
1
Consent to Being Evaluated for a Third Party
242
1
Form 18. Consent form and contract for psychological testing and evaluation
243
1
Form 19. Form for consent to being evaluated for a third party
244
1
Intake and Assessment Forms and Procedures
245
66
Creating the Client's Chart
245
2
The Chronology of Record Keeping
245
1
The Contents of the Record
246
1
Phase I: The Initial Telephone Contact
247
3
Reasons for Refusing a Caller as a Client
248
1
Getting the Essential Data
248
2
Phase 2: The Preappointment Package and Other Types of Preappointment Contact
250
7
Form 20. First-contact record
251
1
Ways to Respond before the Initial Appointment
252
1
Form 21. Appointment card or slip
253
1
Form 22. Letter of appointment confirmation
254
1
Ways of Dealing with No-Shows and Early Dropouts
255
2
Phase 3: The New Client's Arrival for a First Meeting
257
29
Ways of Collecting Further Client Information
257
1
Obtaining Client Demographic Information
258
1
Form 23. Client demographic information form
259
3
Obtaining Client Clinical Information
262
1
Form 24. Client clinical information form
263
4
Obtaining Client Medical Information
267
1
Form 25. Brief health information form
268
4
Assessing Chemical Use
272
1
Form 26. Chemical use survey
273
2
Obtaining Financial Information
275
1
Form 27. Financial information form
276
3
Assuring Financial Responsibility
279
1
Problem Checklists
279
1
Form 28. Agreement to pay for professional services
280
2
Form 29. Adult checklist of concerns
282
2
Form 30. Child checklist of characteristics
284
2
Obtaining Developmental Information
286
1
Phase 4: First Meeting with a New Client
286
14
Form 31. Child developmental history record
287
3
Preparing the Client for the Intake Interview
290
1
Using the Intake Interview Questions and Guide
291
1
Collecting Information from Young Adults
291
1
Special Considerations for Interviewing a Child
291
1
Form 32. Intake interview questions and guide
292
2
Form 33. Information form for young adults
294
3
The Evaluation of Mental Status
297
1
Form 34. Mental status evaluation and report
298
2
Phase 5: Summarizing the Intake Information
300
11
Summarizing Chemical Use and Suicide Risk Data
300
1
Formulating the Whole Case
300
2
Form 35. Chemical user's case formulation
302
2
Form 36. Suicide risk assessment summary and recommendations
304
2
Form 37. Intake summary and case formulation
306
5
Planning and Then Documenting Treatment
311
52
Treatment Planning
311
15
Issues
311
1
Guidelines for Treatment Planning
312
1
Systems and Formats of Treatment Planning
313
1
Other Points in Planning Treatment
314
2
Formulating Treatment Plans for Managed Care Organizations
316
2
Form 38. Individualized treatment plan for managed care organizations
318
7
About Managed Care Organizations' Own Checkoff Forms
325
1
Documenting Treatment's Progress
326
21
Note Taking: Guidelines and Suggestions
326
10
The Problem-Oriented Record
336
2
Form 39. Problem list for a problem-oriented record (POR)
338
2
Form 40. POR progress note form
340
1
Figure 5. Completed sample of a POR progress note form
341
1
Two Structured Progress Note Forms
342
1
Form 41. Structured progress note form
343
2
Client-Generated Records
345
1
Form 42. Structured progress note form for group therapy
346
1
Evaluating Each Therapy Session
347
1
Case Termination
347
8
Reasons for Terminating or Transferring a Patient
347
1
Form 43. Session evaluation questionnaire for clients
348
3
How to Terminate Treatment in Different Situations
351
4
The Case Closing Summary
355
2
Outline for Dictation
356
1
A Termination Summary Form
357
1
Assessing Client Satisfaction and Outcomes
357
6
Client Satisfaction Measures
357
1
Form 44. Termination summary form
358
1
Outcome Assessment Questionnaires
359
1
Cover Letters for These Questionnaires
359
2
Form 45. Client satisfaction follow-up questionnaire
361
1
Form 46. Client outcome follow-up questionnaire
362
1
Confidentiality and Releasing Records
363
58
Understanding Confidentiality
363
13
Basic Definitions
363
2
Exceptions to Confidentiality
365
3
Other Points about Confidentiality and Its Limitations
368
2
Confidentiality and Children
370
1
Confidentiality and HIV-Positive Clients
370
1
A Handout on the Limits of Confidentiality
371
1
Handout 8. Patient handout on the limits of confidentiality
372
4
Maintaining Confidentiality
376
6
Guidelines for Maintaining Confidentiality
376
3
A Checklist for Staff Training in Confidentiality
379
1
Creating Confidential Records
380
1
A Quick Test
381
1
Releasing Clients' Records
382
13
A Pretest
382
1
Ethical Considerations in Releasing Records
383
1
Legal Requirements for a Release of Records
384
1
Eight Variations on the Theme of ``Please Send Your Records''
385
8
Guidelines and Considerations in Sending Records
393
1
Comments on the Pretest
394
1
Forms for Requesting and Releasing Information
395
4
A Briefer Request/Release Form
395
1
A More Comprehensive Request/Release Form
395
1
Form 47. Briefer form for requesting/releasing confidential records and information
396
1
Form 48. Requesting or releasing confidential records and information
397
2
More Specific Forms for Releasing Information
399
7
A Release-of-Records Cover Letter
399
1
Releasing Psychological Test Results
400
1
Form 49. A release-of-records form letter
401
2
Releasing Information to an Attorney
403
1
Form 50. Request/authorization for release of evaluation information
404
1
Form 51. Authorization to release confidential information to an attorney
405
1
Releasing Records to an Insurance Company or Other Third-Party Payer
406
1
Releasing Information to the Patient's Family
406
1
Confidentiality When Faxing Records or Sending E-Mail
406
5
Form 52. Authorization to release confidential information to a health insurer or other third-party payer
407
2
Form 53. Authorization to release confidential information to family members
409
2
Confidentiality Notifications
411
2
Overview of HIPAA
413
8
Health Information and Its Uses
413
1
HIPAA and Privacy
414
1
Becoming ``HIPAA Compliant''
415
1
Notice of Privacy Practices
415
1
Documenting Consent
416
1
The Right to Object or Agree to Uses and Disclosures
417
1
The Right to Limit Disclosure of One's PHI
418
1
An Authorization to Send or Receive Records
418
1
Keeping an Accounting of Disclosures You Made
419
1
When Consent, Authorization, or Opportunity to Object Are Not Required
419
2
APPENDICES: RESOURCES
421
10
Books on Practice Development and Marketing
421
1
Readings in the Law, Ethics, and Malpractice
422
1
Professional Liability Insurance Resources
423
1
Practice Guidelines from Professional Organizations
424
2
Dealing with Managed Care Organizations
426
2
Resources for Supervision and Consultation
428
3
REFERENCES
431
16
INDEX
447
12
Feedback Form
457
2
Instructions for Installing The Paper Office's Forms onto Your Computer
459