Clinical Documentation Glossary

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Affect Anhedonia Avolition Baseline Assessment Behavioral Activation Biopsychosocial Blunted Affect Chief Complaint Circumstantial Speech Clinical Formulation Clinical Impression Cognition Cognitive Restructuring Comorbidity Congruent Affect Dialectical Behavior Therapy Differential Diagnosis Discharge Summary Dissociation EMDR Exposure Therapy Flight Of Ideas Functional Impairment Hypervigilance Insight Judgment Labile Medical Necessity Mental Status Exam Mindfulness Based Intervention Mood Motivational Interviewing Orientation Outcome Measures Perception Presenting Problem Prognosis Progress Notes Psychoeducation Psychomotor Psychotherapy Notes Risk Assessment Screening Tools Severity Rating Tangential Speech Therapeutic Alliance Thought Content Thought Process Treatment Goals Treatment Plan

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Further Reading

  • APA Documentation Guidelines — Offers detailed guidelines on clinical documentation practices specific to psychology and mental health professionals.
  • DSM-5-TR — Provides standardized diagnostic criteria essential for clinical documentation in mental health.
  • HHS HIPAA — Covers legal requirements for protecting patient information within clinical documentation.

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