Forms & Documentation
Although the industry still requires a lot of paperwork to treat, you can now do most of the work through an electronic health record (EHR) system. Most EHR's should supply the paperwork you will need and they even make a way for you to add your own branding/ logo. BHealthy paperwork is available for purchase for $25. We also offer our policy manual for $100. We know it's pricey, but it took us two interns and 6 months to draft it, we're saving you the headache and cost :) Our paperwork was approved by OHMAS (Ohio department of mental health and addiction services) so your safe to adopt it and make it your own. Some tips and tricks will follow.
If you have paperwork you are willing to share, please contact us and we would love to add it to our library!
Helpful Links:
​HIPPA & Privacy
Health Information Privacy to professionals
Health Information Privacy to Others
Health information Privacy to friends & Family
Health information Privacy to police & Fire
Health information Privacy for mental health information
Health information Privacy for substance and alcohol
Summary of HIPAA Security Rule
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Link: HealthyPlace Psychological Exams (Source Sondermind)
Link: Psychological Tests (found on Mental Health America)
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AIMS (for prescribers)
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Bipolar Spectrum Diagnostic Scale (BSDS)
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Clinical Global Impressions Scale (CGI)
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Geriatric Depression Scale (GDS-S, GDS-L)
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Hamilton Anxiety Scale (HAM-A)
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Hamilton Depression Rating Scale (HAM-D)
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Major Depressive Inventory (MDI)
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Mood Disorder Scale (MDQ)
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Pediatric Symptom Checklist - Parent Report
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PHQ-9
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Psychosis Symptom Severity Rating Scale (PSSR) file:///C:/Users/Vanessa%20Barrientes/Downloads/APA_DSM5_Clinician-Rated-Dimensions-of-Psychosis-Symptom-Severity%20(1).pdf
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Quick Inventory of Depressive Symptomatology, Clinician Rated (QIDS-C)
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Quick Inventory of Depressive Symptomatology, (Adolescent)
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QIDS-SR
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Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS)
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Vanderbilt ADHD Diagnostic Teacher Rating Scale (VADTRS)
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Young Mania Rating Scale (YMRS)
How to write a clinical Note ​
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Dictation
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American (Dictation)
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Dragon Notes (Dictation app store)
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Nuance (Dictation)
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SUKI Notes (Dictation)
Active verbs & phrases that can be used to document mental health services MHS) interventions
Progress Note Phrases
Clinical Documentation Guide Sample
Clinical Documentation Manual Sample
Clinical Documentation The Golden Thread Sondermind
Clinical Documentation Ideas
Clinical Documentation Tool
Informed Consent Requirements state by state
Commonly Used words in Clinical Documentation
Acknowledged
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Actively Listened
Addressed
Advised
Advocated
Asked
Assisted
Assisted client in
Asked
Affirmed
Challenged
Challenging
Coached
Checked In
Clarified
Collaborated
Commended
Confronted
Conducted
Conveyed
Crisis Intervention
De-escalated
Demonstrated
Developed
Directed
Discussed
Educated
Empathized
Empowered
Ensured
Established
Explained
Explored
Expressed
Encouraged
Explained
Examined
Explored
Evaluated
Facilitated
Focused on
Focusing/Refocusing
Framing/Reframing
Gave homework
Guided
Goal (setting)
Highlighted
Honoring
Identified
Information Giving/Gathering
Informed
Interacted
Interpreted
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Instructed
Interpreted
Introduced
Inquired about
Joined
Listened
Modeled
Observed
Physical Activity
Played
Praised
Presented
Probed
Problem Solving
Prompted
Paraphrased
Performed
Planned
Practiced
Praised
Prompted
Provided
Redirected
Reflected back
Reframed
Refocused
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Reinforced
Responded to
Reviewed
Role played
Rapport-building
Recapped
Recommended
Redirected
Reflected
Reflective Listening
Reframed
Reinforced
Reiterated
Reminded
Reviewed
Role-played
Social Skills Practice
Suggested
Supported
Set boundaries
Shared
Supported
Trained
​Teaching/Lecturing
Urge
Validated
Documentation: While there are multiple ways to document, the easiest and most efficient is narrative note taking, ie. taking notes during the session verbatim as you and the client interact. Most EHR's have a scan upload feature. Its fast, easy and note submission takes 5 minutes or less. We recommend taking a class on documentation with your local board for CEU's (continuing education units). NEVER give medical or legal advice. Practice within your scope. Notes should always be unique to the client, even in groups.
Always apply ASAM when working with state insurance. Get training in ASAM if you are not familiar. The ASAM manual can be purchased online. The Asam Criteria is treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions 3rd ed. Edition. It's important to learn it and use it in your work.
There is no one way to document, try several and see what fits you and your flow during sessions. Remember, go through the paperwork with the client, a proper intake is informed consent and going through the biopsychosocial. Anything you write down becomes permanent record. Take good notes but don't overdo it (in case notes are subpoenaed, you want the client to be protected).
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Forms Templates: Forms may vary by state. Talk to your state licensing board.
Practice Paperwork Packet for The Columbus Wellness Center
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EAP Form- supplied by the client's employer. Companies require the form not just the number
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