The Adolescent Psychotherapy Progress Notes Planner E-Book

David J. Berghuis

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Practice Planners
• Sprache: Englisch

Seitenzahl: 989

Veröffentlichungsjahr: 2014

Beschreibung

Save hours of time-consuming paperwork with the bestselling therapist's resource The Adolescent Psychotherapy Progress Notes Planner, Fifth Edition, contains more than 1,000 complete prewritten session and patient descriptions for each behavioral problem in The Adolescent Psychotherapy Treatment Planner, Fifth Edition. The prewritten notes can be easily and quickly adapted to fit a particular client need or treatment situation. The Fifth Edition: * Provides an array of treatment approaches that correspond with the behavioral problems and new DSM-5 diagnostic categories in the corresponding companion Treatment Planner. * Organizes treatment for over 30 main presenting problems, including conduct disorder, chemical dependence, low self-esteem, suicidal ideation, ADHD, sexual acting out, and eating disorders. * Provides over 1,000 prewritten progress notes summarizing patient presentation and treatment delivered. * Offers sample progress notes that conform to the requirements of most third-party payors and accrediting agencies, including The Joint Commission, COA, CARF, and NCQA. * Saves clinicians hours of time-consuming paperwork, yet offers the freedom to develop customized progress notes. * Presents new and update information on the role of evidence-based practice in progress notes writing and the special status of progress notes under HIPAA.

Leseprobe

Table of Contents

Cover

Practice Planners®

PracticePlanners® Series

Title Page

Copyright

Dedication

PRACTICEPLANNERS® SERIES PREFACE

ACKNOWLEDGMENTS

PROGRESS NOTES INTRODUCTION

ABOUT PRACTICE

PLANNERS®

PROGRESS NOTES

HOW TO USE THIS

PROGRESS NOTES

PLANNER

A FINAL NOTE ABOUT PROGRESS NOTES AND HIPAA

ACADEMIC UNDERACHIEVEMENT

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

ADOPTION

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

ANGER CONTROL PROBLEMS

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

ANXIETY

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD)

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

AUTISM SPECTRUM DISORDER

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

BIPOLAR DISORDER

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

BLENDED FAMILY

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

CONDUCT DISORDER/DELINQUENCY

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

DIVORCE REACTION

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

EATING DISORDER

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

GRIEF/LOSS UNRESOLVED

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

INTELLECTUAL DEVELOPMENTAL DISORDER

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

LOW SELF-ESTEEM

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

MEDICAL CONDITION

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

NEGATIVE PEER INFLUENCES

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

OBSESSIVE-COMPULSIVE DISORDER (OCD)

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

OPPOSITIONAL DEFIANT

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

OVERWEIGHT/OBESITY

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

PANIC/AGORAPHOBIA

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

PARENTING

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

PEER/SIBLING CONFLICT

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

PHYSICAL/EMOTIONAL ABUSE VICTIM

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

POSTTRAUMATIC STRESS DISORDER (PTSD)

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

PSYCHOTICISM

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

RUNAWAY

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

SCHOOL VIOLENCE

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

SEXUAL ABUSE PERPETRATOR

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

SEXUAL ABUSE VICTIM

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

SEXUAL IDENTITY CONFUSION

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

SEXUAL PROMISCUITY

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

SOCIAL ANXIETY

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

SPECIFIC PHOBIA

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

SUBSTANCE USE

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

SUICIDAL IDEATION

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

UNIPOLAR DEPRESSION

CLIENT PRESENTATION

INTERVENTIONS IMPLEMENTED

End User License Agreement

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Guide

Cover

Table of Contents

PROGRESS NOTES INTRODUCTION

PracticePlanners® Series

Treatment Planners

The

Complete Adult Psychotherapy Treatment Planner, Fifth Edition

The

Child Psychotherapy Treatment Planner, Fifth Edition

The

Adolescent Psychotherapy Treatment Planner, Fifth Edition

The

Addiction Treatment Planner, Fifth Edition

The

Continuum of Care Treatment Planner

The

Couples Psychotherapy Treatment Planner, Second Edition

The

Employee Assistance Treatment Planner

The

Pastoral Counseling Treatment Planner

The

Older Adult Psychotherapy Treatment Planner, Second Edition

The

Behavioral Medicine Treatment Planner

The

Group Therapy Treatment Planner

The

Gay and Lesbian Psychotherapy Treatment Planner

The

Family Therapy Treatment Planner, Second Edition

The

Severe and Persistent Mental Illness Treatment Planner, Second Edition

The

Mental Retardation and Developmental Disability Treatment Planner

The

Social Work and Human Services Treatment Planner

The

Crisis Counseling and Traumatic Events Treatments Planner, Second Edition

The

Personality Disorders Treatment Planner

The

Rehabilitation Psychology Treatment Planner

The

Special Education Treatment Planner

The

Juvenile Justice and Residential Care Treatment Planner

The

School Counseling and School Social Work Treatment Planner, Second Edition

The

Sexual Abuse Victim and Sexual Offender Treatment Planner

The

Probation and Parole Treatment Planner

The

Psychopharmacology Treatment Planner

The

Speech-Language Pathology Treatment Planner

The

Suicide and Homicide Treatment Planner

The

College Student Counseling Treatment Planner

The

Parenting Skills Treatment Planner

The

Early Childhood Intervention Treatment Planner

The

Co-Occurring Disorders Treatment Planner

The

Complete Women's Psychotherapy Treatment Planner

The

Veterans and Active Duty Military Psychotherapy Treatment Planner

Progress Notes Planners

The

Child Psychotherapy Progress Notes Planner, Fifth Edition

The

Adolescent Psychotherapy Progress Notes Planner, Fifth Edition

The

Adult Psychotherapy Progress Notes Planner, Fifth Edition

The

Addiction Progress Notes Planner, Fifth Edition

The

Severe and Persistent Mental Illness Progress Notes Planner, Second Edition

The

Couples Psychotherapy Progress Notes Planner, Second Edition

The

Family Therapy Progress Notes Planner, Second Edition

The

Veterans and Active Duty Military Psychotherapy Progress Notes Planner

Homework Planners

Couples

Therapy Homework Planner, Second Edition

Family

Therapy Homework Planner, Second Edition

Grief

Counseling Homework Planner

Group

Therapy Homework Planner

Divorce

Counseling Homework Planner

School

Counseling and School Social Work Homework Planner, Second Edition

Child

Therapy Activity and Homework Planner

Addiction

Treatment Homework Planner, Fifth Edition

Adolescent

Psychotherapy Homework Planner, Fifth Edition

Adult

Psychotherapy Homework Planner, Fifth Edition

Child

Psychotherapy Homework Planner, Fifth Edition

Parenting

Skills Homework Planner

Veterans

and Active Duty Military Psychotherapy Homework Planner

Client Education Handout Planners

Adult

Client Education Handout Planner

Child

and Adolescent Client Education Handout Planner

Couples

and Family Client Education Handout Planner

Complete Planners

The

Complete Depression Treatment and Homework Planner

The

Complete Anxiety Treatment and Homework Planner

The Adolescent Psychotherapy Progress Notes Planner

Fifth Edition

Arthur E. Jongsma, Jr.

L. Mark Peterson

William P. McInnis

David J. Berghuis

Cover Design: Wiley

Cover Images: © Ryan McVay/Getty Images

This book is printed on acid-free paper.

Copyright © 2014 by Arthur E. Jongsma, Jr., L. Mark Peterson, William P. McInnis, and David J. Berghuis. All rights reserved.

Published by John Wiley & Sons, Inc., Hoboken, New Jersey

Published simultaneously in Canada

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, [phone], fax [phone], or on the web at www.copyright.com. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, [phone], fax [phone], or online at www.wiley.com/go/permissions.

Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no representations or warranties with the respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional where appropriate. Neither the publisher nor the author shall be liable for damages arising herefrom.

For general information about our other products and services, please contact our Customer Care Department within the United States at [phone], outside the United States at [phone] or fax [phone].

Wiley publishes in a variety of print and electronic formats and by print-on-demand. Some material included with standard print versions of this book may not be included in e-books or in print-on-demand. If this book refers to media such as a CD or DVD that is not included in the version you purchased, you may download this material at http://booksupport.wiley.com. For more information about Wiley products, visit www.wiley.com.

Library of Congress Cataloging-in-Publication Data:

Jongsma, Arthur E., Jr., 1943-

The adolescent psychotherapy progress notes planner / Arthur E. Jongsma, Jr., L. Mark Peterson, William P. McInnis, David J. Berghuis. – Fifth edition.

1 online resource. – (PracticePlanners series)

Includes bibliographical references.

Description based on print version record and CIP data provided by publisher; resource not viewed.

ISBN 978-1-118-81668-4 (ebk) – ISBN 978-1-118-81664-6 (ebk) – ISBN 978-1-118-06676-8 (pbk) 1. Adolescent psychotherapy–Handbooks, manuals, etc. 2. Medical records–Handbooks, manuals, etc. I. Peterson, L. Mark. II. McInnis, William P. III. Berghuis, David J. IV. Title.

RJ503

618.92′8914–dc23

2013046013

To the memory of Rick Smeenge, adolescent social worker and wonderful friend, who taught me what it means to dance the soft shoe. I miss you, Rick.

Arthur E. Jongsma, Jr.

To my children, Katy and Mike. You make your mother and me proud.

David J. Berghuis

To Breanne, Kelsey, and Andrew, for all the love you bring in my life.

William P. McInnis

To Harold Kunze, in gratitude for 40 years of close friendship.

L. Mark Peterson

PRACTICEPLANNERS® SERIES PREFACE

Accountability is an important dimension of the practice of psychotherapy. Treatment programs, public agencies, clinics, and practitioners must justify and document their treatment plans to outside review entities in order to be reimbursed for services. The books and software in the PracticePlanners® series are designed to help practitioners fulfill these documentation requirements efficiently and professionally.

The PracticePlanners® series includes a wide array of treatment planning books including not only the original Complete Adult Psychotherapy Treatment Planner, Child Psychotherapy Treatment Planner, and Adolescent Psychotherapy Treatment Planner, all now in their fifth editions, but also Treatment Planners targeted to specialty areas of practice, including:

Addictions

Co-occurring disorders

Behavioral medicine

College students

Couples therapy

Crisis counseling

Early childhood education

Employee assistance

Family therapy

Gays and lesbians

Group therapy

Juvenile justice and residential care

Mental retardation and developmental disability

Neuropsychology

Older adults

Parenting skills

Pastoral counseling

Personality disorders

Probation and parole

Psychopharmacology

Rehabilitation psychology

School counseling and school social work

Severe and persistent mental illness

Sexual abuse victims and offenders

Social work and human services

Special education

Speech-language pathology

Suicide and homicide risk assessment

Veterans and active military duty

Women's issues

In addition, there are three branches of companion books that can be used in conjunction with the Treatment Planners, or on their own:

Progress Notes Planners

provide a menu of progress statements that elaborate on the client's symptom presentation and the provider's therapeutic intervention. Each

Progress Notes Planner

statement is directly integrated with the behavioral definitions and therapeutic interventions from its companion

Treatment Planner

.

Homework Planners

include homework assignments designed around each presenting problem (such as anxiety, depression, chemical dependence, anger management, eating disorders, or panic disorder) that is the focus of a chapter in its corresponding

Treatment Planner

.

Client Education Handout Planners

provide brochures and handouts to help educate and inform clients on presenting problems and mental health issues, as well as life skills techniques. The handouts are included on CD-ROMs for easy printing from your computer and are ideal for use in waiting rooms, at presentations, as newsletters, or as information for clients struggling with mental illness issues. The topics covered by these handouts correspond to the presenting problems in the

Treatment Planners

.

Adjunctive books, such as The Psychotherapy Documentation Primer and The Clinical Documentation Sourcebook, contain forms and resources to aid the clinician in mental health practice management.

The goal of our series is to provide practitioners with the resources they need in order to provide high-quality care in the era of accountability. To put it simply: We seek to help you spend more time on patients, and less time on paperwork.

Arthur E. Jongsma, jr.Grand Rapids, Michigan

ACKNOWLEDGMENTS

I am again deeply indebted to David Berghuis, who managed the project of updating this fifth edition of The Adolescent Psychotherapy Progress Notes Planner. He is responsible for modifying the evidence-based chapters to make them coordinate exactly with the new fifth edition of The Adolescent Psychotherapy Treatment Planner. Thank you, Dave, for your fine work.

AEJ

PROGRESS NOTES INTRODUCTION

ABOUT PRACTICEPLANNERS® PROGRESS NOTES

Progress notes are not only the primary source for documenting the therapeutic process, but also one of the main factors in determining the client's eligibility for reimbursable treatment. The purpose of the Progress Notes Planner series is to assist the practitioner in easily and quickly constructing progress notes that are thoroughly unified with the client's treatment plan.

Each Progress Notes Planner:

Saves you hours of time-consuming paperwork.

Offers the freedom to develop customized progress notes.

Features over 1,000 prewritten progress notes summarizing patient presentation and treatment delivered.

Provides an array of treatment approaches that correspond with the behavioral problems and

DSM-IV

and

DSM-5

diagnostic categories in the corresponding companion

Treatment Planner

.

Offers sample progress notes that conform to the requirements of most third-party payors and accrediting agencies, including JCAHO, COA, CARF, and NCQA.

HOW TO USE THIS PROGRESS NOTES PLANNER

This Progress Notes Planner provides a menu of sentences that can be selected for constructing progress notes based on the behavioral definitions (or client's symptom presentation) and therapeutic interventions from its companion Treatment Planner. All progress notes must be tied to the patient's treatment plan—session notes should elaborate on the problems, symptoms, and interventions contained in the plan.

Each chapter title is a reflection of the client's potential presenting problem. The first section of the chapter, “Client Presentation,” provides a detailed menu of statements that may describe how that presenting problem manifested itself in behavioral signs and symptoms. The numbers in parentheses within the Client Presentation section correspond to the numbers of the Behavioral Definitions from the Treatment Planner.

The second section of each chapter, “Interventions Implemented,” provides a menu of statements related to the action that was taken within the session to assist the client in making progress. The numbering of the items in the Interventions Implemented section follows exactly the numbering of Therapeutic Intervention items in the corresponding Treatment Planner.

All item lists begin with a few keywords. These words are meant to convey the theme or content of the sentences that are contained in that listing. The clinician may peruse the list of keywords to find content that matches the client's presentation and the clinician's intervention.

It is expected that the clinician may modify the prewritten statements contained in this book to fit the exact circumstances of the client's presentation and treatment. To maintain complete client records, in addition to progress note statements that may be selected and individualized from this book, the date, time, and length of a session; those present within the session; the provider; provider's credentials' and a signature must be entered in the client's record.

A FINAL NOTE ABOUT PROGRESS NOTES AND HIPAA

Federal regulations under the Health Insurance Portability and Accountability Act (HIPAA) govern the privacy of a client's psychotherapy notes, as well as other protected health information (PHI). PHI and psychotherapy notes must be kept secure and the client must sign a specific authorization to release this confidential information to anyone beyond the client's therapist or treatment team. Further, psychotherapy notes receive other special treatment under HIPAA; for example, they may not be altered after they are initially drafted. Instead, the clinician must create and file formal amendments to the notes if he or she wishes to expand, delete, or otherwise change them.

Does the information contained in this book, when entered into a client's record as a progress note, qualify as a “psychotherapy note” and therefore merit confidential protection under HIPAA regulations? If the progress note that is created by selecting sentences from the database contained in this book is kept in a location separate from the client's PHI data, then the note could qualify as psychotherapy note data that is more protected than general PHI. However, because the sentences contained in this book convey generic information regarding the client's progress, the clinician may decide to keep the notes mixed in with the client's PHI and not consider it psychotherapy note data. In short, how you treat the information (separated from or integrated with PHI) can determine if this progress note planner data is psychotherapy note information. If you modify or edit these generic sentences to reflect more personal information about the client or you add sentences that contain confidential information, the argument for keeping these notes separate from PHI and treating them as psychotherapy notes becomes stronger. For some therapists, our sentences alone reflect enough personal information to qualify as psychotherapy notes and they will keep these notes separate from the client's PHI and require specific authorization from the client to share them with a clearly identified recipient for a clearly identified purpose.

ACADEMIC UNDERACHIEVEMENT

CLIENT PRESENTATION

Academic Underachievement (1)

1

The client's teachers and parents reported a history of academic performance that is below the expected level given the client's measured intelligence or performance on standardized achievement tests.

The client verbally admitted that his/her current academic performance is below his/her expected level of functioning.

The client has started to assume more responsibility for completing his/her school and homework assignments.

The client has taken active steps (e.g., studying at routine times, seeking outside tutor, consulting with teacher before or after class) to improve his/her academic performance.

The client's academic performance has improved to his/her level of capability.

Incomplete Homework Assignments (2)

The client has consistently failed to complete his/her classroom or homework assignments in a timely manner.

The client has refused to comply with parents' and teachers' requests to complete classroom or homework assignments.

The client expressed a renewed desire to complete his/her classroom and homework assignments on a regular basis.

The client has recently completed his/her classroom and homework assignments on a consistent basis.

The client's regular completion of classroom and homework assignments has resulted in higher grades.

Disorganization (3)

Parents and teachers described a history of the client being disorganized in the classroom.

The client has often lost or misplaced books, school papers, or important things necessary for tasks or activities at school.