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A Practical Guide to Documentation in Behavioral Health Care, Fourth Edition

Help staff at all levels effectively prepare and use documentation that supports safe, high-quality care, treatment, and services!

November 2012. 164 pages. Includes CD.

Product Description

Product Description

A Practical Guide to Documentation in Behavioral Health Care, Fourth Edition, has been updated to include the latest information in documenting behavioral health care treatment. The revised edition emphasizes the necessity of supportive documentation and examines its role in meeting clinical and management needs in a variety of settings. The examples throughout this book illustrate ways behavioral health care organizations have successfully documented assessments; plans of care, treatment, or services; and processes such as medication reconciliation, progress notes, and resource allocation and maintenance.
Key Topics: 
  • Expanded discussion on the growing use of electronic records
  • Relevant documentation requirements
  • Focus on the “person-centered care” model that encourages individuals served to invest in their own recovery
  • Recovery-oriented care systems 
  • Integrating physical care into behavioral health care 
Key Features:
  • Companion CD containing interactive sample forms 
  • Exercises designed to help improve documentation skills  
  • Updated tools and forms 
  • Appendix providing relevant Joint Commission requirements related to documentation
Standards: Record of Care, Treatment, and Services (RC); Provision of Care, Treatment, and Services (PC); Performance Improvement (PI)
Setting: Behavioral Health Care
Key Audience:  
  • Administrators
  • Service program Directors
  • Clinical staff and leaders
  • Performance improvement specialists
  • Accreditation professionals
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