3 tips for improving your patient collaborative documentation

collaborative documentation

Of the many best practices flooding into the field of behavioral health, collaborative documentation is an approach which can easily get overlooked by agencies focused on clinical documentation improvement. This is unfortunate as it’s an approach which can lend itself in surprising ways for engagement of clients and effective/efficient recording of service delivery. Since a common place all clinicians find themselves from time to time is at an impasse with clients, why not give it a try? 

Not only can the process be appealing to many clients, it is also a useful tool for clinicians who want to promote clients taking greater ownership of their treatment. The concept of co-authoring clinical documents with your client may seem too big of a change to commit to at first. Getting started may be the hardest part so here are 3 bases to cover for successfully implementing collaborative documentation for you and your client. 

  1. Positioning and set up of your desk and office
  2. Suspending your disbelief and plan for it
  3. Be creative and willing to learn

1. Positioning and set up of your desk and office. This is not a new concept for therapy. I know plenty of clinicians, myself included, who have taken the time to pull some Zen or sensorimotor techniques into the office in order to impact therapy and client interaction in a positive way. Along with the adoption of electronic health records comes the ease of access to clinical documentation, which makes collaborating with your clients a natural next step. 

Being mindful of how collaborative documentation feels and impacts the experience of the client during a session is as important as seating, lighting, and colors for establishing a comfortable therapeutic environment. Position your client’s space, yourself and your workstation to be as conducive to eye contact and interaction as possible. You wouldn’t want to be sitting with your primary care physician and have the back of a computer screen to look at when disclosing sensitive health information, and you certainly don’t want to leave wondering if the doctor heard all of what you shared. 

Eye contact is the key confirmation that a person was hearing you. With adequate eye contact throughout a session, you wouldn’t walk away questioning if you received quality care. 

Quality of care is a common barrier and concern I’ve heard from clinicians when suggesting implementation. “The quality of my sessions with my clients would not be the same.”  The idea of it is shot down before being given a fair chance and this denies the possibility of positive outcomes to be discovered. I know, because I shot it down. When I first heard of the concept of co-authoring my clinical documents with my clients, I pushed it aside as unlikely. I wasn’t hooked until I took a look at it from the vantage point of my client. 

Being able to co-author my medical record with my doctor? Yes, of course, I’m the expert on me, not my doctor. I was won over by the idea and potential to collaborate more effectively with my doctor by adding to his expertise with me being the expert on me. So I gave client collaboration a try. This leads to my second important base for success.  

2. Suspending your disbelief and plan for it. For your first three or four sessions this is a must. Not much gets done in life without some form of planning. Keep in mind that “even the best laid plans of mice and men often go awry.” What do we tell our clients?  “Trust the process.” Be planful in selecting the right client to start off with and do a test run of your set-up with a peer or supervisor. 

You will know which of your clients would be the better to start with. The one who indicates some interest in what you’re putting into their chart.  Or one who you can tap into their interest in writing or who you can empower to have a stronger voice. Technology is solidly planted in how the world operates and maybe the collaborative documentation approach will quell any anxieties about “what are you inputting into that electronic health record about me.” The point being, think it over and select the client you would be most comfortable with and who is workable, then have a backup plan to shift course as needed. 

Avoid my pitfalls of not selecting the most appropriate client and not planning for the session. I dove into this effort with my least workable client; not recommended. I can recall it like it was yesterday. The novelty of co-authoring the progress note with me wore off after 10 minutes (or less) and my young client was pulling out all his tricks of diversion and distraction. I was committed to the process and didn’t shift along with my client’s needs who ended up getting “bored” and asked to end the session early.    

Read other treatment planning tips in the blog post Measurable goals and objectives in data informed treatment planning.

3. Be creative and willing to learn. Taking something away from each attempt is standard issue for what I’ve observed among my clinical peers, and creativity is one of the most common and natural skill-sets a clinician possesses. Creativity is tapped into for overcoming any seemingly impossible barriers to treatment. There are clinical approaches which arise from the ability of clinicians to be creative and learn from each session. Let this skill-set help you launch your implementation and your perceived challenges won’t stand a chance against your creative can-do attitude. 

I had many creative ideas after the fact with my first attempts and I implemented many of them along the way. Being willing to learn from each experience will build a bridge from where you are now to a successful and rewarding option for clinical documentation improvement.

Given the industry’s transition to electronic heath records, there really is no better time to consider adding collaborative documentation to your clinical toolbox. Flipping through paper charts is a cumbersome experience and opening up multiple documents on a workstation is a fragmented process. The ease of being in an electronic record lends to easy access for viewing progress over time with clients, collaborating on recording each session, and capturing your client’s signature.  From this place you may open doors you had unknowingly walked passed before.   

Read more about treatment planning in the White Paper, The 6-Sigma Clinician.

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Topics: Clinical Practice