Hundreds of thousands of students and early-career professionals have relied on this authoritative report-writing tool, now updated for DSM-5/ICD-10-CM and newer types of evaluations. In a convenient large-size format with lay-flat binding, the book covers nearly all areas of concern addressed in intakes, evaluations, treatment plans, progress notes, and closing summaries. The user seeking the right wording for a clinical document can skim and select from thousands of technical terms, behavioral descriptors, and standard statements. Also provided are interview questions for almost every symptomatic behavior, a huge collection of mental status questions, a reproducible Mental Status Evaluation summary form, and links to hundreds of Internet resources. The periodically updated companion website offers all the URLs from the book, the reproducible forms, and a handy reference on current psychiatric medications.
 
New to This Edition
*A unique list of all psychiatric ICD-10 diagnoses (all of the codes in DSM-5, plus many more), including Z codes essential to a comprehensive biopsychosocial evaluation.
*Sample evaluation report keyed to the book's chapters.
*Sections on additional clinical issues: intimate partner violence, gender identity, human trafficking, recovery-oriented language, and more.
*Many more Internet links, including a wide variety of screening and assessment tools.
 
See also The Paper Office for the Digital Age, Fifth Edition, by Edward L. Zuckerman and Keely Kolmes, which provides the essential recordkeeping and risk-reduction tools that every psychotherapy practice needs.

Edward L. Zuckerman, PhD, consults and creates effective practice tools for clinicians. He found his life’s passion while working as a psychiatric aide at New York’s Bellevue Hospital in the 1960s. Dr. Zuckerman has worked with adults in a variety of clinical contexts, acted as liaison with state hospitals, taught undergraduates, and maintained an independent practice in general clinical psychology for many years. He lives in rural western Pennsylvania.

Getting Oriented to the Clinician’s Thesaurus
A Functional Guide to Report Construction
I. Conducting a Mental Health Evaluation
1. Beginning and Ending the Interview
2. Mental Status Evaluation Questions/Tasks
3. Questions about Signs, Symptoms, and Other Behavior Patterns
II. Standard Terms and Statements for Wording Psychological Reports
A. Introducing the Report
4. Beginning the Report: Preliminary Information
5. Referral Reasons
6. Background Information and History
B. The Person in the Evaluation
7. Behavioral Observations
8. Responses to Aspects of the Examination
9. Presentation of Self
10. Emotional/Affective Symptoms and Disorders
11. Cognition and Mental Status
12. Abnormal Signs, Symptoms, and Syndromes
13. Personality Patterns
C. The Person in the Environment
14. Activities of Daily Living
15. Social/Community Functioning
16. Couple and Family Relationships
17. Vocational/Academic Skills
18. Recreational Functioning
19. Other Specialized Evaluations
D. Completing the Report
20. Summary of Findings and Conclusions
21. Diagnostic Statement/Impression
22. Recommendations
23. Prognostic Statements
24. Closing Statements
III. Useful Resources
25. Treatment Planning and Treatment Plan Formats
26. Formats for Reports, Evaluations, and Summaries
27. Listing of Common Psychiatric and Psychoactive Drugs
28. Psychiatric Masquerade of Medical Conditions
Appendices
A. Abbreviations in Common Use
B. Annotated Readings in Assessment, Interviewing, and Report Writing
C. Internet Resources Cited in the Clinician’s Thesaurus
Feedback Solicitation Form
References