When you think about clinical documentation, what does it represent for you and your practice?
Depending on the practice, the answer may vary. For some, documentation is a struggle—even to the extent that providers hope for a no-show or a cancellation in order to spend the time catching up. Other practices that don’t have this particular problem might still note a distinct separation between documentation and the context of care.
Regardless of the practice’s circumstances, however, the thought of adding a collaborative element in documentation might seem like a lot of extra effort toward something for which there already isn’t enough time. But practices must also account for the positives of collaborative documentation, and there are a lot to consider.
In addition, newer tools—such as AI-assisted documentation—are beginning to change how practices approach collaboration, making it easier to involve clients in the process without adding as much administrative burden.
The Pros and Cons of Collaborative Documentation
The following is a list of pros and cons of adopting collaborative documentation for assessments, treatment plans, and progress notes, to give practices a better idea of whether or not it can work for them.
The Pros
1. Can Save Significant Time
Imagine having all documentation responsibilities wrapped up before the client leaves the building. Depending on the circumstances of the practice, this could represent a huge time savings. Execution is critical, however, and the degree of success a practice will realize depends largely on personal commitment and how well technology is leveraged.
With the addition of AI-assisted documentation, some practices are finding new ways to support this goal. Draft notes can be generated from session content and refined quickly, helping reduce the amount of documentation work that may need to be completed after the session ends.
2. Fits a Person-Centered Therapy Model
Practices that specialize in person-centered therapy will find collaborative documentation is not a far leap. As clients and therapists work through the process and discover solutions, collaborating over progress and outcomes is the logical next step.
Technology can support this approach by helping organize key discussion points into structured documentation, making it easier to reflect shared understanding while keeping clinicians in control of the final note.
3. Helps Practices Reach Increasing Performance Demands
With the industry’s leanings toward an eventual value-based care standard, keeping clinical work focused on outcomes is very important. Having patient collaboration baked into clinical workflows improves visibility into progress.
Tools that help structure documentation and highlight key clinical elements can also support more consistent tracking of outcomes over time.
4. Improves Engagement
Patients or clients who can offer their perspectives regarding services and progress will help providers to offer clarity on important issues. Furthermore, patients and clients who feel empowered during the care process will consistently drive positive results.
When documentation becomes part of the conversation—rather than something completed afterwards—it can reinforce transparency and shared understanding.
The Cons
1. Writing is a Contemplative Process for Some
The challenge for some providers is in the impromptu nature of creating documentation on the spot. Providers each have their own processes, and some prefer to be thorough and thoughtful with their writing.
Even with newer tools that assist in generating draft notes, clinicians still need time to review, edit, and ensure the documentation reflects their clinical judgment.
2. Disruption of the Therapeutic Relationship
Emotional availability is the cornerstone of care for most practices. Although by and large, patients are growing accustomed to seeing technology in a place of care, the dynamics are invariably altered once a laptop is placed between client and therapist.
For this reason, many practices look for ways to minimize distraction—whether that means limiting in-session documentation or using tools that allow notes to be completed more efficiently after the session. Read more about how practices incorporate technology into a session.
3. Writing With the Client is Not Billable
According to current industry standards, collaborative documentation is not a billable procedure. This is an important consideration for practices anticipating extra time for collaboration.
Improving efficiency in other parts of the documentation process can help offset this challenge, particularly when clinicians are able to complete notes more quickly overall.
4. Requires a Significant Shift in Thinking
Managing documentation with someone within a session, as opposed to alone afterwards, is going to make a dramatic difference for a lot of practices. Providers that have already settled into a comfortable rhythm and a system that’s working well are going to be less receptive to the notion of making such a significant change.
However, as documentation tools evolve, practices have more flexibility in how they approach this shift, adapting workflows gradually rather than making an all-or-nothing change.
Integrating Collaboration in 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.
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 who 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 note-taking 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 that 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 a 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.
See How AI Notes Assist Can Support Collaborative Documentation
Regardless of where your practice’s stance is on collaborative documentation, there are a lot of important considerations to keep in mind. Understanding the pros and cons of collaborative documentation in a clinical setting will help practices to understand what works best for their needs.
Valant’s AI Notes Assist helps clinicians generate structured draft notes and streamline documentation workflows, supporting more efficient note completion after sessions—all within a behavioral health–specific EHR.
By making documentation faster and easier to manage, it becomes more practical to involve clients in the process without adding to your administrative workload. Learn more about AI Notes Assist and how it supports your documentation workflow.
