Skip to main content

Part 2: integrating collaboration into the clinical process in 5 steps

Time is a precious resource for any private behavioral health practice. Managing it effectively means smoothing out several interdependent clinical and administrative workflows, with documentation representing a significant part of that. Collaborative documentation can offer value in terms of both time and patient-provider interaction, but it represents a significant shift in thinking for which the practice may or may not be ready.

To learn more about the pros and cons of collaborative documentation, see part 1.

Incorporating collaborative documentation into the practice’s routine doesn’t require a complete teardown of existing processes. Making the transition is fairly easy, provided some important steps are observed.

1. Consider the office layout
Providers put a lot of thought into the layout of their therapy spaces, and with good reason; the layout can have a significant impact on the success of care. Just as much thought needs to go into an arrangement that can accommodate collaborative documentation. For providers that are accustomed to writing notes post-session, the most significant challenge will be planning around the inclusion of a device, such as a laptop or a tablet. Each provider will need to assess his or her circumstances and layout and determine the best way to execute, but don’t be surprised if a little adjustment of the furniture (or even the decorations) is required.

2. Ensure the right technology is in place
If notetaking is a significant disruption to the session, it will hinder outcomes. Collaborative documentation should only be attempted if it is fast and efficient. The good news is many technology solutions provide features that make this possible. Providers should be especially interested in EHR features like drop-down selection, integrated measures, and auto narrative generation, all of which help to create seamless fusion between documentation and clinical care.

3. Use appropriate scripting
Collaborative documentation is a departure from existing healthcare paradigms for the patient as well—not just the practice. Setting the right tone for collaboration is key, as the patient might not be familiar with the concept. When working through a session, it’s important to emphasize ownership: your notes, your progress, your treatment plan, etc. Focus on how patient feedback contributes to the development and maintenance of treatment goals, because it does!

4. Create an employee pilot program
A pilot program is useful in determining the value of collaborative documentation to the practice before making a full-on commitment to it. It is, after all, a decision that shouldn’t be made lightly. Select some key staff to spearhead the effort. Carefully assess success metrics over time, including time saved, outcomes improved, trust built between provider and patient, processes streamlined, etc. It’s entirely possible that the practice won’t be satisfied with the results, which is totally fine; collaborative documentation is not going to work for every practice.

5. Do what you can
Even for practices that are fully committed to collaborative documentation, it will not work out with every client in every situation. It can be particularly challenging with children, and in some cases it should not even be attempted (with patients experiencing crisis, for example). But despite the failures a practice might encounter along the way, they generally aren’t representative of the effectiveness of collaborative documentation on the whole. Failures to implement it into daily clinical life are often the result of a focus on the exceptions to the rule, and not the rule itself.

It is ultimately up to practices to determine whether or not collaborative documentation is right for them. There is a shift in care dynamics that might not sit well for certain practices, depending on circumstances, but for those for whom it will work, there is a strong likelihood of realizing significant returns.

Want to see how Valant’s Behavioral Health EHR can help your practice achieve collaborative documentation?