Impact of Collaborative Documentation on Completeness and Length of Clinical Notes in Behavioral Health Settings

Nari Yoo, Elizabeth Matthews, Daniel Baslock, Victoria Stanhope

Research output: Contribution to journalArticlepeer-review

Abstract

OBJECTIVE: This study aimed to examine differences in community mental health visit notes before and after initiation of collaborative documentation, a practice in which clinicians and consumers jointly document clinical encounters. METHODS: Using a clinical informatics approach, the authors sampled visit notes (N=1,875) from nine providers in one mental health clinic. The authors compared notes from before and after the implementation of collaborative documentation by using fixed-effects regression models, controlling for therapist-level effects. RESULTS: Significant changes in visit note structure were found after the implementation of collaborative documentation. Most sections (N=6 of 10) contained more information (i.e., higher word and character counts) after collaborative documentation implementation, but sections describing a client's feelings were less likely to have any content (OR=0.01, p<0.001). CONCLUSIONS: These findings demonstrate that collaborative documentation influences clinical notes, providing much-needed research about a widely adopted practice in community mental health settings.

Original languageEnglish (US)
Pages (from-to)186-190
Number of pages5
JournalHospital and Community Psychiatry
Volume75
Issue number2
DOIs
StatePublished - Feb 1 2024

Keywords

  • Clinical documentation
  • Collaborative documentation
  • Community mental health
  • person-centered care

ASJC Scopus subject areas

  • Psychiatry and Mental health

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