Collaborative documentation standards | Reading homework help


Plagiarism free, APA is required for this assignment, Review three scholarly resources on the benefits and limitations of collaborative documentation solid academic writing is expected. Need back on Tuesday March 13, 2018 by 6:00 p.m.

After reviewing the collaborative documentation PowerPoint, identify the essential elements needed to document a service the same day it occurred.

Write 750 words; define collaborative documentation standards and the benefits of using this approach in a community mental health and wellness center. Review three scholarly resources on the benefits and limitations of collaborative documentation and write a comparative analysis between the positions for or against it. Describe the basic outcome measures used in healthcare and how using collaborative documentation will assist with better outcomes.


Collaborative Documentation PowerPoint 

Benefits of CD


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?

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 

1. 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

3.  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’

4%   stated ‘Average’

0%   reported Poorly’

1%   reported ‘Very Poorly’ 

2% had No Opinion/No Answer 

Continue with CD 

4. On a Scale of 1 to 3, in the future, would you want your provider to continue to review your note with you?  

77%  said YES! 

11%  were unsure  

6%  said NO 

6%  had No Answer/NA 

Outpatient Pilot 

Selected interested clinicians from 4 outpatient sites to go through a collaborative documentation training (webinar) and management provided ongoing support/guidance (N=242). Used the same 4 question survey from National Council 

77% of clients reported it either ‘Very Helpful’ or ‘Helpful’ to have their provider review notes with them at the end of session (similar to national average)  

80%  of clients reported they felt either Very Involved or Involved (Likert  Scale) in their care (similar to national data) 

Outpatient Data 

88%  of clients reported their provider did a ‘Very Good’ or ‘Good’ job with introducing the system  

72% of clients reported they would want their provider to continue the CD method 

Overall, data from this pilot was similar to national average in terms of client      responses/reactions to CD 

Staff Reactions to CD 

100% of the staff who were surveyed had implemented CD for one or more months  

83%  reported it was either ‘Very Easy’ or ‘Easy’ to learn collaborative documentation vs. 16% of staff who reported it was ‘Not Easy.’  

58%  reported CD is helpful to the treatment process vs. 33% who reported it   was ‘Neither Helpful nor Not Helpful.’  

50%  reported clients were either ‘Very Involved’ or ‘Involved’ in the treatment  process as a result of CD (77% of clients reported feeling involved in their care) 

75% reported CD has been helpful with paperwork efficiency 

50% reported better workplace satisfaction with the use of CD 

Research on Nonverbal Communication 

A  study out of Northwestern evaluated eye gaze patterns between PCPs and patients while electronic health records are used 

100 patient visits were observed and video-taped in 10 PCP offices 

Researchers wanted to assess eye contact as it relates to using electronic health record systems vs. paper charts 

Investigators interested in how EHR affects the quality of the patient/physician interaction Possible design guidelines indicated 


Given that nonverbal communication is being explored as an important aspect to treatment, eye contact, body language, posturing, and facial  expressions are vital when using an EHR system  

This  study found patients eyes go where the physicians eyes go (patients gazed  at their doctor 50% of the visit vs. doctors gaze patterns towards patients, which was 47% of the visit) 

Physician initiated eye gaze was found to be an important driver of interactions between the patient/physician




Healthy work/life balance? 

4-6  weeks to transition fully into CD mode 

Addressing concerns as they arise 

Seeking guidance/support from management during the initial phase  



Asan, O., Montague, E. (2014). Dynamic modeling of patient and physician eye gaze to understand the effects of electronic health records on doctor-patient communication and attention. International Journal Of Medical Informatics. Vol 83, 225-234. 

Schmelter, B. (2013). Collaborative documentation gets you off the compliance treadmill. Retrieved from 

Stanhope, V., Ingolia, C., Schmelter, B., Marcus, S.C. (2013). Impact of person-centered planning and collaborative documentation on treatment adherence. Psychiatric Services, Vol 64, 1, 76-80. 

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