Collaborative documentation, or client-centered treatment planning, is an excellent tool to improve the effectiveness and efficiency of behavioral healthcare. While more county and state organizations are implementing it, still many organizations have some hesitancy.
What is collaborative documentation? As defined by Bill Schemelter of MTM Services, “Collaborative Documentation is a clinical strategy in which the clinician reviews the session with the client as they document this in the record (e.g. goals and objectives addressed, interventions provided, progress in meeting goals and objectives, clients response to the sessions today, and the plan/recommendations for things the client and if applicable the clinician will do prior to the next session). It replaces the clinical “wrap-up”, using a written medium to reinforce the above important aspects of the session/interaction.”
Why is collaborative documentation so vital? According to a presentation by Katherine Hirsch, LCSW from MTM, the following challenges currently exist:
1. Documentation has become “The ENEMY”
2. Clinicians report that documentation competes with time spent with clients
3. Clinicians count on “no-shows” to complete paperwork and catch up
4. High documentation to direct service ratio reduces number of scheduled appointments in clinic and in community (negatively impacts service
capacity)
5. Clinician’s paperwork is divorced from their clinical work
6. Clinician’s quality of life is affected!
Ask any clinician about their number one frustration with their work and they will most likely tell you that it’s documentation. Any number of clinicians will complain about how tedious and painstaking the process can be, leading to late evenings and weekends spent on the computer instead of with family. At this time of the Great Resignation, where employees are seeking work that improves their mental health, documentation shouldn’t be one of those tasks that worsens it.
Collaborative documentation simply means that, during or at the end of the session, the clinician writes the notes about the session and asks for the client’s input. The client may see the note or the documentation. It can be done at any time during treatment, such as assessment, treatment planning, progress notes, or transition. With so many clients resistant to treatment and feel like they are non-participants in their care, collaborative documentation can be a way to reverse these trends.
In an article in 2013, researchers used the collaborative documentation approach in community mental health centers, or CMHC’s. What they discovered in comparing this approach vs. the traditional approach of documentation was that medication adherence increased and more engagement (as measured by reduced no-shows) occurred. When clients have more of a sense of control in their care, they participate at a higher level.
Technology programs that advance this process, such as clinical decision-making and electronic health record applications, are valuable in making the clinical session more client-friendly.
Praxes provides consulting and behavioral health software to organizations. For more information, please contact us.
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PRAXES is a nationwide behavioral health software, consulting, and training company. No one in the behavioral health industry has a better reputation, and if you give us the chance, we’ll show you why! At PRAXES, our services improve the efficiency and structure of behavioral health agencies serving children and families nationwide. PRAXES brings over 45 years of administrative and clinical expertise. With more than 100 client companies nationwide, we offer the expertise to advance the quality of behavioral health services. We accomplish these goals through our new clinical decision software, our training of best practices, and helping companies meet regulatory standards. At PRAXES, we believe in being creative and fostering new ways to serve children and their families. Our vision is to empower the families our agencies serve with skills that not only improve their functioning, but help them to thrive in their everyday lives. When you give us the chance, you’ll be connected directly to our friendly staff, so you can expect immediate attention to your inquiry. So, don’t wait, call now!
Dan Thorne has unique perspectives on the field of mental health. As a clinician, he has had over 40 years of experience working with clients in the Southern California area. After obtaining his Bachelor’s degree from the University of California at Irvine, he worked with children in the Orange County Juvenile Hall. Here he honed his earliest techniques on at-risk children. After that, he obtained his Master’s degree in Counseling from California State University, Fullerton.
In the 1990’s, Dan turned his attention to the clinical and administrative side of behavioral health organizations. For three years, he was the Assistant Administrator of Starting Point, a chemical dependency facility in Costa Mesa, CA. In 2001, he took an opportunity to be the Director of Harbor View Community Services Center in Long Beach. When he arrived, the Center had only 80 clients and 13 staff. When he left, there were over 400 clients and 75 staff. Dan created several programs through their contract with the Los Angeles County Departments of Mental Health and Child and Family Services. Under his guidance, Harbor View became one of the leading providers of children’s services in Los Angeles County.
While improving the results of the client’s parents at the Center, Dan reflected on his experiences as a parent. His children themselves had special needs such as mental and intellectual challenges, and Dan knew the toll it takes on the parent. In order to help the child, the parent has to be healthy. From this concept, he created his parenting program. After years of refining it, teaching it to his staff at the Center, and then taking the results and comments from these efforts, he became the developer of the current PRAXES program. It is a culmination of Dan’s personal trials and tribulations as a parent along with empirical results and research of over 40 parenting programs.
Our vision at PRAXES is to advance the strength of parents and caregivers of children with special needs (mental health, intellectual, or physical) through education, support, and empowerment. Thus, they can live healthy and functional lives while caring for the child.
Apogee is a clinical decision software designed to help behavioral health practitioners with their treatment and patient engagement. It provides evidence-based and research-based components. Not only do they consist of elements from such practices as Cognitive Behavior Therapy, Seeking Safety, Dialectical Behavior Therapy, Motivational Interviewing, Functional Behavior Analysis, but also the Intensive Models for Parents, Youth, and Children.
PRAXES has over 30 years of accreditation experience. We know what it takes to get your organization accredited. Whether it’s Joint Commission, CARF, or COA, our team can provide an evaluation of your current status and review the standards which need improvements. We will assist you with the policies, documentation, and training required to be accredited.
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