National Council Survey
National Council Survey
Collaborative Documentation (CD)
Completing All or most of the documentation with the individual during the time of the service
Benefits of CD
Efficient
Allows our clients to know what is in their charts
Clarify information
Include client perspectives
Clients will become more engaged and involved in their treatment
Specific treatment outcomes can be discussed
Change in treatment plan can be addressed more quickly (emphasis on collaboration)
CD and Clinical Practice
Collaborative Documentation integrates documentation into clinical practice
Documentation becomes useful to the interests and values of practitioners
Documentation becomes timely (real time)
Client participation will improve
Focus on treatment goals/objectives
Intake Process with CD
Non clinical staff collect the non-clinical information (demographics)
Completing all Information- gathering collectively
Allowing clients to view the computer screen
Pointing to the computer screen and alternating between listening and summarizing
Depending on client presentation, some parts of the assessment may be completed post session (e.g., mental status exam).
Tips for Psychiatric Providers
Start by asking ‘What do we want to result from our work over the next few months? How will we know we if we’re successful?’
Measurable or observable outcomes
What can we do together to move towards your goal (e.g., how medication monitoring services will assist in the overall treatment goal)
Changes in functioning, behaviors, symptoms, skills
Additional Tips
‘I may be typing while you are answering some of my questions so that I am not missing any information shared with me.’
Alternating between listening, summarizing, and eye gaze will assist in building a therapeutic alliance.
Completing the note during intervals (whatever works for the individual-some clients may need a brief break or a change in focus)
More Tips!
Allow the individual and family to see the note!
Agree to Disagree
Think of CD as written ‘wrap up’ versus paperwork
Control documentation to enhance the clinical process
Invite clients to share their values/perspectives
Use formatted notes (thank you, HMS!)
Attitude is KEY-present CD as an invitation
Office Setup
Where is your desk in relation to where clients sit?
How is your computer positioned?
Are you facing clients ?
Are you able to turn your screen so clients can see what you’re typing?
Is your office conducive to CD?
Office Setup
Clinical Benefits
Highly positive responses from individuals/families
Improved recall and plan adherence
Improved Engagement-reductions in NO SHOWS/CANCELLATIONS
More time to see clients and meet the needs of the community
Data from 10 CMHCs
10 community mental health centers were randomly assigned to receive training in person-centered planning and collaborative documentation or provide treatment, as usual (N=17,000)
Medication Adherence and Service Engagement were measured over 11 months
RESULTS-Medication Adherence increased significantly in the experimental group (B=.022, p<.01) but showed no significant change in the control condition (B=.004, p=.25). Appointment no shows were also reduced in the experimental group.
National Council Survey
- On a Scale of 1 to 5, how helpful was it to have your provider review your note with you at the end of session?
81% stated it was either ‘Very helpful’ (51%) or ‘Helpful’ (30%)
9% stated it was ‘Neither Helpful’ or ‘Nor Not Helpful’
1% stated it was ‘Not Helpful’
5% stated it was ‘Very Unhelpful’
4% had No Opinion/NA
Involvement in Care
- On a scale from 1 to 5, how involved did you feel in your care, compared to past experiences? (either with us or another agency)
51% stated they felt ‘Very Involved’
28% felt ‘Involved’
14% felt ‘About the Same’
1% felt ‘Not Involved’
3% felt ‘Uninvolved’
3% N/A or No Opinion
Provider Approach
- On a Scale of 1 to 5, how well do you think your provider did in introducing and using this new system?
68% reported ‘Very Good’
25% reported ‘Good’
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