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Part 1: The pros and cons of collaborative documentation

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.

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

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 be leveraged.

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.

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.

Improves engagement

Patients or clients that are able to offer their perspectives in regards to services and progress will help providers to offer clarity on important issues. Furthermore, patients and clients that feel empowered during the care process will consistently drive positive results.

The cons

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.

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.

To read more about how practices incorporate technology into a session, click here.

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.

Requires a significant shift in thinking

Managing documentation with someone within session as opposed alone afterward 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.

Regardless of where the 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.

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