August 2009  << Back  

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The Paper Office. Forms, Guidelines, and Resources to Make Your Practice Work Ethically, Legally, and Profitably. Fourth edition

Richard Balon, MD

Wayne State University, Detroit, MI, USA

We live in the age of forms, paperwork, rules, regulations, and truly overwhelming bureaucracy. Relatively simple things are becoming quite complicated. Like everything else, the business of private practice has become more complicated, even in psychiatry, psychology, and other areas of mental health care. Yet, most teaching programs—residencies, fellowships, and internships—do not really teach the nuts and bolts of running a private practice business. One learns it on the job, but how and from whom? Since 1991, Edward Zuckerman, a clinical psychologist and consultant and creator of practice tools for clinicians, has been publishing a text that may help anybody in private practice—novice or experienced practitioner. His book, The Paper Office. Forms, Guidelines, and Resources to Make Your Practice Work Ethically, Legally, and Profitably, is in its fourth edition. While this book is written for psychologists, it seems that other mental health professionals practicing psychotherapy can benefit from it.

By Edward L. Zuckerman; The Guilford Press; New York, New York; 2008; ISBN 978-1-59385-835-3; pp 476; $65.00 (paperback).

The volume consists of 7 chapters and 7 brief appendices (resources). The titles of the chapters—”Basic paperwork and communication tools”; “Financial tools and procedures”; “Reducing malpractice risk by operating ethically”; “Getting informed consent”; “Intake assessment forms and procedures”; “Planning and then documenting treatment”; and “Confidentiality and releasing records”—are self-explanatory. Each chapter contains well-organized, mostly easy-to-read text explaining the particular topic, and a number of forms (55 forms and 6 handouts; all can be modified) are stored on an enclosed disk or could be photocopied.

The Introduction suggests that using this text will make the reader less vulnerable when doing clinical work, more efficient, more profitable, and stable as a business. It also explains what this book contains (brief guidelines and checklists; paper resources; and is designed to function as “a malpractice risk reduction kit”); its unique features, and how one should use it. The author also offers that the reader may send him any criticism, modification, or additional forms to be used in the next revision of this book (the contributor would get full credit for this and a free copy of the next edition).

The chapter on basic paperwork reviews office administration basics, such as presenting oneself on paper, starting with guidelines for clear and ethical self-presentation (how to use and not to use one’s degree, what not to use “around” one’s name), what stationary and business cards should look like (eg, do not use abbreviations, they are tacky and do not save space [p 12], how many cards and on what kind of paper), how to put together a résumé and curriculum vitae, organizing the appointment book, basic record keeping (what form, paper or electronic), making records safe, how long to keep records, and how to dispose of them.

The second chapter on finances is similarly detailed and useful. It contains a good discussion about fees and ethical guidelines (eg, ethically, financial arrangements must be made in advance of treatment so that consent to treatment is fully informed and fee splitting should be only for service provided and not for referral), how to set fees (cost-plus pricing, competitive pricing, pricing by negotiation, pricing by time, pricing by setting an income goal), various fee arrangements (discounts, sliding fees, self-pay arrangements for confidentiality, prices for forensic evaluation and school services), fee collection tips (no big balance because it may tempt patients to devise malpractice suits or ethics complaints to escape them), how to keep income records, various billing methods, and others.

The next chapter advises the reader how to ethically operate the private practice to reduce the risk of malpractice. The author reminds us that most malpractice cases arise from problems that could have been avoided if only they were recognized and anticipated (p 79). The chapter discusses issues such as when patients sue, what to do if there is a complaint against the practitioner (whom to talk to and not to talk to); and various types of malpractice insurance (occurrence-based vs claims-made policies). The author also provides 22 steps for risk reduction and discusses the risks of psychological testing. The final parts of this chapter deal with boundary violations (including a good evaluation questionnaire whether one is in trouble with a patient in regards to boundary violations); dual or multiple relationships; sexual intimacies in therapy (including reporting another therapist); the duty to protect and warn; assessment of patient’s dangerousness to self and others; ethical and legal issues in working with managed care organizations (what to do when joining the panel, dealing with managed care organization reviewers, educating patients about managed care, the dubious concept of “medically necessary” care); and the legal and ethical aspects of supervising and being supervised. This is a very useful and relatively unexpected chapter for a book on “paper aspects” of private practice.

The chapter focused on getting informed consent is equally detailed and, considering the topic, a bit boring. It discusses, among others, the different paths to informed consent to treatment. The chapter contains samples of informed consent one can use. The following chapter reviews the intake assessment procedures and forms, starting with the initial telephone contact (including reasons to refuse accepting the patient), followed by reviews of the pre-appointment package, ways of dealing with no-shows and early dropouts (eg, shortening the waiting time until appointment, offering services at alternative hours, phone and card reminders, etc.), and the first meeting with a new patient—again with plenty of forms and specific guidelines.

The next chapter reviews treatment planning and documentation of treatment. The author reminds us that the entire subject of treatment planning is in flux (p 330). The chapter provides guidelines, systems and formats of treatment planning, and guidance on how to formulate treatment plans for managed care organizations. The part on documentation discusses, among others, the issue of psychotherapy notes vs regular notes. The final part of this chapter focuses on terminating and transferring a patient. The final chapter deals with confidentiality and releasing records. It includes a good discussion of confidentiality when treating children. Other interesting parts of this chapter are the review of “8 variations on the theme ‘please send your records,’” and confidentiality involving faxing and using e-mail in communication with patients.

The 7 “resource” appendices include: A. Books on practice development and marketing; B. Readings in the law, ethics, and malpractice; C. Professional liability insurance resources (sellers of insurance); D. Practice guidelines from professional organizations (not the American Psychiatric Association!); E. Dealing with managed care organizations (includes a list of newsletters and books); F. Resources for supervision and consultation; and G. Resources on record privacy and security.

This book is obviously intended for psychologists. However, I am not aware of a similar text for psychiatrists, and I believe that private practice psychiatrists may find this book useful as a starting point for arranging and organizing their practice, or as a guidance to updating their business practice. The enclosed disk (for Windows and Mac) with numerous forms and the nonassignable (meaning it could be used only by the book purchaser) permission to reproduce the handouts and forms make it a really good investment. As Dr. Zuckerman notes in the introduction, “This book cannot contain everything (!? -mine) you should know to be in independent practice; it does contain all you need to make the correct initial decisions about office practice and paperwork, and so it will help you to start out right” (p 1). I would say that for $65 this is really well spent for any private practitioner in mental health.