Overview

Featuring contributed chapters written by experts in the discipline, Clinical Documentation for Mental Health Clinicians: Introduction of Service to Discharge and Everything in Between provides guidance for mental health clinicians to competently navigate the complexities of clinical documentation. Addressing a gap in existing literature, this book serves as a manual for the documentation process from intake to discharge. Recognizing the significant role clinical documentation plays in treatment planning and legal compliance, the text offers detailed scenarios and instructive content for mental health professionals to effectively record client interactions. The content presents an exploration of ethical and legal considerations, clear language usage, and key aspects of clinical reporting. The work spans essential topics such as informed consent, release of information, intake assessments, case conceptualization, treatment planning, case notes to discharge summaries, and documentation of crisis situations. By providing vivid case studies, practitioners are shown the practical aspects of chronicling client information in a manner that upholds clinical integrity and meets ethical and regulatory standards. Clinical Documentation for Mental Health Clinicians is an ideal text for undergraduate and graduate courses that aim to prepare students for the practical realities of mental health documentation. Its structured coverage ensures relevance for courses focusing on clinical practice, counseling techniques, and the administrative components of mental health services.

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Mona Gallo is an associate professor of counseling at Lindsey Wilson College and a professional counselor specializing in practice with adults, couples, and families. She holds an Ed.D. in counseling psychology from Argosy University Orange CA and a master's degree in community counseling from Argosy University Chicago.

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