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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: Practice Planners
- Sprache: Englisch
Save hours of time-consuming paperwork with the bestselling treatment planning system The Adult Psychotherapy Progress Notes Planner, Fifth Edition contains complete prewritten session and patient presentation descriptions for each behavioral problem in The Complete Adult Psychotherapy Treatment Planner, Fifth Edition. The prewritten progress notes can be easily and quickly adapted to fit a particular client need or treatment situation. * Saves you hours of time-consuming paperwork, yet offers the freedom to develop customized progress notes * Organized around 43 behaviorally based presenting problems, including depression, intimate relationship conflicts, chronic pain, anxiety, substance abuse, borderline personality, and more * Features over 1,000 prewritten progress notes (summarizing patient presentation, themes of session, and treatment delivered) * Provides an array of treatment approaches that correspond with the behavioral problems and DSM-5 diagnostic categories in The Complete Adult Psychotherapy Treatment Planner, Fifth Edition * Offers sample progress notes that conform to the requirements of most third-party payors and accrediting agencies, including CARF, The Joint Commission (TJC), COA, and the NCQA * Identifies the latest evidence-based care treatments with treatment language following specific guidelines set by managed care and accrediting agencies
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Seitenzahl: 941
Veröffentlichungsjahr: 2014
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Table of Contents
Cover
Contents
Practice
Planners
® 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
ANGER CONTROL PROBLEMS
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
ANTISOCIAL BEHAVIOR
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
ANXIETY
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
ATTENTION DEFICIT DISORDER (ADD)—ADULT
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
BIPOLAR DISORDER—DEPRESSION
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
BIPOLAR DISORDER—MANIA
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
BORDERLINE PERSONALITY
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
CHILDHOOD TRAUMA
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
CHRONIC PAIN
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
COGNITIVE DEFICITS
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
DEPENDENCY
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
DISSOCIATION
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
EATING DISORDERS AND OBESITY
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
EDUCATIONAL DEFICITS
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
FAMILY CONFLICT
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
FEMALE SEXUAL DYSFUNCTION
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
FINANCIAL STRESS
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
GRIEF/LOSS UNRESOLVED
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
IMPULSE CONTROL DISORDER
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
INTIMATE RELATIONSHIP CONFLICTS
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
LEGAL CONFLICTS
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
LOW SELF-ESTEEM
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
MALE SEXUAL DYSFUNCTION
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
MEDICAL ISSUES
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
OBSESSIVE-COMPULSIVE DISORDER (OCD)
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
PANIC/AGORAPHOBIA
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
PARANOID IDEATION
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
PARENTING
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
PHASE OF LIFE PROBLEMS
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
PHOBIA
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
POSTTRAUMATIC STRESS DISORDER (PTSD)
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
PSYCHOTICISM
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
SEXUAL ABUSE VICTIM
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
SEXUAL IDENTITY CONFUSION
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
SLEEP DISTURBANCE
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
SOCIAL ANXIETY
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
SOMATIZATION
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
SPIRITUAL CONFUSION
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
SUBSTANCE USE
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
SUICIDAL IDEATION
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
TYPE A BEHAVIOR
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
UNIPOLAR DEPRESSION
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
VOCATIONAL STRESS
CLIENT PRESENTATION
INTERVENTIONS IMPLEMENTED
End User License Agreement
Guide
Cover
Table of Contents
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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 Treatment 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 Adult Psychotherapy Progress Notes Planner
Fifth Edition
Arthur E. Jongsma, Jr.
David J. Berghuis
Cover image: © Ryan McVay/Getty ImagesCover design: Wiley
This book is printed on acid-free paper.
Copyright © 2014 by Arthur E. Jongsma, Jr., 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, (978) 750-8400, fax (978) 646-8600, 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, (201) 748-6011, fax (201) 748-6008, 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 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 (800) 762-2974, outside the United States at (317) 572-3993 or fax (317) 572-4002.
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- author.The adult psychotherapy progress notes planner / Arthur E. Jongsma, Jr., David J. Berghuis. -- Fifth edition.1 online resource. -- (Practice planners series)ISBN 978-1-118-41872-7 (ebk.) -- ISBN 978-1-118-41586-3 (ebk.) -- ISBN 978-1-118-06675-1 (pbk.)1. Psychotherapy--Handbooks, manuals, etc. 2. Medical records--Handbooks, manuals, etc. 3. Adulthood--Psychological aspects--Handbooks, manuals, etc. 4. Mental illness--Treatment--Handbooks, manuals, etc. I. Berghuis, David J., author. II. Title.RC480.5616.89'14--dc23
To my manuscript manager, Sue Rhoda, who has brought to the task wonderful organizational skills and a genuine warmth and pleasantness.
Arthur E. Jongsma, Jr.
To my wife, Barbara, with all my love.
David J. Berghuis
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
Again, I am deeply indebted to David Berghuis, who managed the project of updating this fifth edition of The Adult 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 Complete Adult Psychotherapy Treatment Planner. Thank you, Dave, for your fine work.
A.E.J.
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; the 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.
ANGER CONTROL PROBLEMS
CLIENT PRESENTATION
Episodic Excessive Anger (1)
*
The client described a history of loss of temper in response to specific situations.
The client described a history of loss of temper that dates back many years, including verbal outbursts and property destruction, typically related to specific emotional themes.
As treatment has progressed, the client has reported increased control of his/her situational episodic excessive anger.
The client has had no recent incidents of episodic excessive anger.
General Excessive Anger (2)
The client shows a pattern of general, excessive anger across many situations.
The client does not appear to be experiencing anger in response to specific issues, but as a general pattern.
As treatment has progressed, the client has verbalized insight into his/her pattern of excessive anger.
The client has made progress in controlling his/her pattern of excessive anger.
Cognitive Biases Toward Anger (3)
The client shows a pattern of cognitive biases commonly associated with anger.
The client makes demanding expectations of others.
The client tends to generalize labeling the targets of his/her anger.
The client tends to have anger in reaction to perceived slights.
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
