Collaborative Documentation Standards

Grand Canyon University: MHW649

In the United States, healthcare providers are given guidelines to follow in regard to maintaining and keeping patient or client information. These guidelines are regulated by both federal and states laws. According to the American Psychological Association (2020),collaborative documentation should include the intake and the treatment plan with recommendation.Also, all medical records must be maintained appropriately according to the ethical principles of the profession, again all documentation and recordings must be done the same day at the time of service to promotes information accuracy (apa.org, 2020). The purpose of the client’s visit, the type of medical setting and lengths of visit would determine the extent of the documentation. However, professionals must always follow the ethical principles requirement for documenting and keeping records within their professional filed (Mathioudakis, Rousalova, Gagnat, Saad, & Hardavella, 2016). Having a proper records maintenance will help the professional document the treatment plan, service provided and progress notes for the entire treatment period. A well documentation of client’s visit would help the client and protect professional in the event of legal lawsuit and malpractice or during any ethical proceedings. A proper record is a requirement for professionals to get reimbursement for services provided and in case of referral to other providers or facility.

The benefits and limitation of collaborative documentation is something that cannot be ignored in the in the health care settings. Knowing both the benefits and the limitation would help the professional to make ethical decisions and also help to promotes a positive patient outcome. The benefit would help to integrate medical information and the care service plan. It will also improve the client participation with his or her care. Again, it will help the client to comply with treatment procedures, hence helps the client to focus on treatment which promotes positive outcomes. However, collaborative documentation cannot be use aguideline in psychotherapy treatment process, and with the functions of collaborative documentation there has been a little significancedemonstration of the mechanisms that are reliable for the conclusions with the use of collaborative documentation in psychotherapy. Furthermore, most therapist do not like documentation, they see it as the “enemy” because they believe documentation takes away time that could be used for clinical activities. Professionals believes that documentation takes time away from the time they could spend on treating client, so documentation should be integrated with treatment session (Hirsch, 2017).

In addition, some professionals believe that collaborative documentation does not promote therapeutic relationship between the client and the therapist. It can sometimes discourage the client to participate in his or her care. Because of the states and the federal laws regarding documentation, the professionals may focus more on documenting than the client. The professional cannot be reimbursed just for documenting progress report so spending less time with the client can affect billing. However, documentation is the only properly way of communicating with the team members in any healthcare settings.

Collaborative documentation is an important tool to use in the mental health field. It helps to improve patient outcomes, by encouraging the client to get involve with treatment plan and care, it also saves the professional time because collaborating with the client would help the professional to have all the necessary information needed before treatment starts. Also working together with the client would strengthen the client and therapist relationship, so the therapist would be transparent to the client’s needs and the client would also be open with the therapist. This would also save the time from writing long notes because all the information needed would be available and the client would be right there to correct and point out to any mistakes and errors in the documentation. In doing so the professional must use words that the client would understand. Using medical terms that are unfamiliar to the client may discourage the client from participation in the documentation and it will negatively impact treatment. Moreover, collaborative documentation details the care plans, treatment plan and the progress report. The treatment plan of the collaborative documentation ensures the compliance of the client and the input of the plan, the progress of the client, their involvement and the implementation of the plan. The professional must update the information of the client as time goes by and whenever necessary or there is change in the client’s conditions. The professional must also be aware of the treatment goals in other to address the client concerns during treatment sessions. Collaborative documentation helps in better outcomes because it cut down on time spent on documenting but increase client and therapist time together which promotes positive outcomes (NCBI, 2013).

American Psychological Association (2020) Ethical Principles. Retrieved from

https://www.apa.org/search?query=Ethical %20principles

Hirsch, K. (2007). SAMHSA-HRSA Center for Integrated Health Solutions. Collaborative

Documentation. Retrieved from

www.integration.samhsa.gov/mai-coc-grantees-online-

community/Breakout4_Collaborative_Documentation.pdf

Mathioudakis, A., Rousalova, I., Gagnat, A.A., Saad, N., & Hardavella, G. (2016). How to keep

Good clinical records. Breathe (sheffeld, England), 12(4), 369-373.

NCBI (2013) Mental Health Collaborative Care and its Role in Primary Care Settings Retrieved

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3759986/

References