TY - JOUR
T1 - Impact of Collaborative Documentation on Completeness and Length of Clinical Notes in Behavioral Health Settings
AU - Yoo, Nari
AU - Matthews, Elizabeth
AU - Baslock, Daniel
AU - Stanhope, Victoria
PY - 2024/2/1
Y1 - 2024/2/1
N2 - 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.
AB - 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.
KW - Clinical documentation
KW - Collaborative documentation
KW - Community mental health
KW - person-centered care
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U2 - 10.1176/appi.ps.20230118
DO - 10.1176/appi.ps.20230118
M3 - Article
C2 - 37528697
AN - SCOPUS:85184148309
SN - 1075-2730
VL - 75
SP - 186
EP - 190
JO - Hospital and Community Psychiatry
JF - Hospital and Community Psychiatry
IS - 2
ER -