Collaborative Documentation:
A Best Practice Intervention
Cummins Behavioral Health
Systems, Inc.
Jessica Rasmussen, LMFT
August 2013
What is Collaborative
Documentation?
• Difference between Collaborative and Concurrent
Documentation.
• Collaborative Documentation is a process in which
clinicians and consumers collaborate in the
documentation of the Assessment, Person-centered
Treatment Plan, and Progress Notes.
• Collaborative Documentation is a clinical tool that
provides consumers with the opportunity to provide their
input and perspective on services and progress, and
allows consumers and providers to clarify their
understanding of important issues and focus on
outcomes.
Importance of CD use with
Home to Stay
• The Home to Stay Program champions a
consumer’s ability to make progress so
they can live an independent and fulfilling
life consistent with their own goals
• CD offers the opportunity for a consumer
to empower themselves to define their
goals and ensure they are holding
themselves and their providers
accountable to those goals
Three Important Aspects
• Person Centered Approach to Treatment
and Documentation
• Improves Treatment Outcomes
• More efficient and Accurate
Documentation
Person-Centeredness
• Research demonstrates improvement
in consumer engagement and
involvement; Fewer no-shows/
cancellations;
• Improved treatment compliance;
• Supports and is Consistent with
Person-Centered Treatment
Planning;
Treatment Outcomes
• Since CD provides consumers with the
opportunity to give their input and perspective
on services and progress- from assessment
to discharge, treatment investment is
increased.
• Allows consumers and clinicians to clarify
their understanding of important issues and
focus on outcomes using solution-focused
philosophy.
-Example: What was heard during the session?
• Evidence-based, supported by research.
Efficiency: Disposing of Time
Wasters and Preventing Burnout
• Collaborative Documentation will:
– Save time and produce quality
documentation
– Help focus the clinical hour / skills session
What is Required for CD?
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A willingness to try it
A computer
For providers in the office: setting up your office.
For providers in the field: a good battery and car charger;
privacy.
Basic keyboarding skills
Personal organization
Use of a structured session
Practice and perseverance
How to begin?
Role Induction
• This is your note, chart, care, and treatment
• Writing the note now will help us ensure a higher
quality note that better represents your progress
• Your opinions and feedback are important in the
development and maintenance of your treatment
goals
• We want to make each service the best possible
service for you that we can
• We will only document during the last few
minutes of your session
Transitional Strategies
• Interact normally with the consumer during
session, taking notes on a pad saying, “I’m
going to jot down some notes so we’ll
remember them when we write our note at
the end of the session.”
• At the end of the session, say, “Let’s
review and write down the important parts
of our session today.”
Role Induction for Existing
Consumers
• “As you know, I normally write notes about our
sessions afterward in my office. We now believe
that there is value in making sure that you
contribute to what is written in your notes. Also,
I want to be sure that what I write is correct and
that we both understand what was important
about our session.”
• “So from now on, at the end of the session, we
will work together to write a summary of the
important things we discuss.”
Common Concerns
• It’s not fair to consumers.
• CD takes away from treatment.
• There is no clinical benefit for children,
paranoid, or psychotic consumers.
• I need time to think about what I want to
write before I complete the note.
• You cannot complete CD during a crisis
situation.
It Works!
•
“Aside from the obvious therapeutic benefits such as better treatment and better notes, it simply
came down to two things with me. It was equal parts selfishness and self discipline. I give 150%
when I am here. I just felt as though I did not need to give another 20% when I got home at
night. I just felt like this was not good “self care” for me or my daughter. The other part was just
good old fashioned self discipline during the appointment with the consumer to set the
expectation, give the cons a reminder when note time was getting close and sticking to my
guns! There are those days that you feel like you are putting out fires but even if I have one night
a week that I have 1 or 2 stragglers to finish Its still been life changing!! And you can quote me on
that! My higher functioning cons really take ownership in the process as well, plus 2 heads is
better than one, right?” --Melynda Yater, Life Skills Specialist for Home to Stay
•
““My consumer who I have worked with for a very long time is paranoid of the computer. But after
a few months of doing collaborative documentation, she is now working on becoming her own
payee. I think it’s because of watching me type out the progress she has been making. She did
not realize she was managing her money as good as she was until I was typing out her progress
and talking about it with her.”-- Stephanie Austin, Life Skills Specialist for Home to Stay”
Summary
• Collaborative Documentation is a clinical
tool to be used with consumers
• CD will improve treatment outcomes,
prevent employee burnout, minimize
organizational risk and increase person
centered care
• CD can begin at any time!