Collaborative Documentation Standards in Community Mental Health and Wellness Centers- Benefits and Limitations

Collaborative Documentation Standards in Community Mental Health and Wellness Centers- Benefits and Limitations

Collaborative documentation (CD) is a practice in which healthcare professionals and patients collaborate in documenting the assessment, episodic notes, and service plan (Maniss & Pruit, 2018). CD allows patients to give their opinions and input on healthcare services and progress made during therapy. Patients and healthcare professionals can seek clarification on important issues and focus on patient outcomes. The patient must be engaged and present in clinical documentation. The CD has numerous benefits and limitations. Healthcare professionals must thus weigh the benefits versus the limitations of CD to help them effectively implement it.

Elements to be Documented

CD involves working with the patient to document the progress of treatment and therapy. It integrates documentation into clinical practice. Collaborative documentation should be done in real time. It improves patient participation in the treatment process and may improve healthcare outcomes. Some critical elements are necessary to document a healthcare service. The critical elements include patient demographics. The non-clinical staff collects information related to demographics (Shapiro & Rusyn, 2019). The healthcare professional should gather information collectively. The information may include presenting problems, family history, and medications, among others. The patient should be allowed to look at where the information they provide is documented. This can be done by allowing the patients to look at the computer screen where the healthcare professional records the information. The healthcare professional should alternate between listening to the patient and summarizing the information provided. They should also take the time to gather comprehensive information and even allow the client to look at the computer screen for further elaboration (Shapiro & Rusyn, 2019). The healthcare professional should give the patient time to respond to their questions. If the patient has an inquiry, the healthcare professional should give helpful responses. Depending on the patient’s symptoms, some parts of the assessment may be completed at the end of the session. An example is the mental status examination.

Collaborative Documentation Standards

Collaborative documentation has many benefits to the patient and the healthcare professional. The benefits of using collaborative documentation in clinical practice include improved responses from clients of a community mental health and wellness center. Clients in a community wellness center benefit from collaborative documentation since they communicate issues they want the healthcare professionals to address. It also reduces the cancellation of appointments and shows improved engagement (Maniss & Pruit, 2018). Through collaborative participation, patients will be more engaged in the treatment and adhere to the plans and schedule set by behavioral professionals. It allows interaction between patients and clinical experts. Clinicians have enough time to meet their clients and consider community needs.

Benefits and Limitations of Collaborative Documentation

Collaborative documentation has many benefits. This method does not cause harm to the patient or the client. It allows the patient to know the information recorded in their medical records (Maniss & Pruit, 2018). This allows them to participate fully in the assessment and treatment process. Using collaborative documentation allows the clinician and the patient to clarify any information they do not understand during the assessment. Clinical documentation also incorporates the patient’s perspectives (Shapiro & Rusyn, 2019). Patients can inquire about the treatment plan, which will allow for engagement and implementation of patient-centered care. The patient and the clinician can discuss the treatment outcomes. The patient can inquire about the treatment plans and voice their input (Matthews, 2020). It can allow changes in the treatment plan. It allows the clinician to effectively communicate the changes to the treatment plan to the patient. Collaborative documentation, however, has its limitations. The documentation process may be contemplative for some clinicians since they have different documentation methods that may not match collaborative documentation. Some patients may also resent the paperwork. Collaborative documentation can also hinder therapeutic relationships since some clients do not see the benefits of technology or may like to share their information (Matthews, 2020). Even though it has limitations, the benefits outweigh them, and hence, clinical documentation should be implemented in clinical settings.

Basic Outcomes Measures

Outcome measures can be defined as the impact of healthcare interventions on a patient’s health status (Pantaleon, 2019). Measures and addressing outcome measures enhance healthcare services. It also allows healthcare organizations to improve their processes and enhance healthcare outcomes. Collaborative outcomes can help improve healthcare outcomes in several ways. It can allow patients to participate in the treatment plan. This can improve medication adherence and patient satisfaction, improving healthcare outcomes. Patients can also give their feedback and express their input into the effects of the treatment plan. This will allow clinicians to address the patient’s concerns and help them develop a treatment plan together.

Conclusion

Collaborative documentation is an emerging practice in the healthcare delivery industry. It allows the patient and clinician to document notes in real-time. The patient can participate in the treatment plan. It improves patient participation, medication adherence, and patient outcomes. It, however, has its limitations, and hence healthcare professionals should choose when to use it with patients.

References

Maniss, S & Pruit, A.G  (2018). Collaborative Documentation for Behavioral Healthcare Providers: An Emerging Practice. Journal of Human Services: Training, Research, and Practice, 3(1), 2. : https://scholarworks.sfasu.edu/jhstrp/vol3/iss1/2

Matthews, E. B. (2020). Computer use in mental health treatment: Understanding collaborative documentation and its effect on the therapeutic alliance. Psychotherapy, 57(2), 119-128. https://doi.org/10.1037/pst0000254

Pantaleon L. (2019). Why measuring outcomes is important in health care. Journal of Veterinary Internal Medicine, 33(2), 356–362. https://doi.org/10.1111/jvim.15458

Shapiro, A., & Rusyn, I. (2019). Health Assessment Workspace Collaborative Documentation.

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In 750-1,000 words, define collaborative documentation standards and the benefits of using this approach in a community mental health and wellness center.

Review at least three scholarly resources on the benefits and limitations of collaborative documentation and write a comparative analysis between the positions for or against it.

Describe the basic outcome measures used in healthcare and how using collaborative documentation will assist with better outcomes.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.