Occupational therapy was founded on two beliefs: that “man, through the use of his hands as they are energized by mind and will, can influence the state of his own health” (p.88) and that illness and unhappiness occur when a person has lost the agency to act on his own behalf (Reilly, 1962). In any setting, occupational therapists focus their services on facilitating optimal functioning of their clientele, such that their minds and wills are energized to use their hands effectively. In a mental health setting, this often involves the implementation of innovative approaches to engage and empower the client throughout the recovery process. One innovative approach that may be integral to the engagement and empowerment of clientele in mental health settings, is collaborative documentation.
Collaborative, or concurrent, documentation (CD) may support the increased implementation of shared decision making while also increasing client empowerment and engagement, improving treatment outcomes, and decreasing emotional burnout on providers. Collaborative documentation changes the focus of assessment, planning, and evaluation documentation by allowing for the client and provider to work together to complete all documentation during face-to-face sessions (Stanhope, Ingoglia, Schmelter, & Marcus, 2013). This type of collaboration throughout the intervention process ensures that the client’s personal goals and values are upheld, that the client and provider leave each session with the same understanding, and that the client is empowered to challenge provider’s assumptions about adherence to treatment. Collaborative documentation is associated with a stronger therapeutic alliance, which is associated with increased client engagement; improved outcomes; and enhanced efficiency and quality of work-life for providers (Maniss & Pruit, 2018).
Collaborative documentation facilitates increased involvement of the client in making decisions for her/his own care because the client is expected to engage as a partner in generating progress notes and intervention plans during each session. Thus, “the role of client changes from one of a mental patient who is written about to a person who is becoming part of the action and part of the solution. This type of empowerment process can drive reductions in the client’s internalization of mental illness stigma” (Sheehan & Lewicki, 2016, p.310) and increase the client’s engagement in the therapeutic process.
One study found “that person-centered planning and collaborative documentation were associated with greater engagement in services (a decrease in no-shows) and higher rates of medication adherence” (Stanhope et al., 2013, p.79), and there is “evidence to suggest that a strong working alliance is related to an increased understanding of the meaning of the interventions utilized during direct service provision. As such, intersession processing and generalization of skills could be promoted through collaborative reflection and synthesis of the session content through a practice like collaborative documentation” (Maniss & Pruit, 2018, p.10-11). Collaborative documentation practices are also associated with improved outcomes and increased medication adherence. In an 11-month study involving clients with schizophrenia and bipolar disorders, medication adherence was significantly more improved at facilities that implemented collaborative documentation (Stanhope et al., 2013).
Despite the fact that clinicians spend nearly one third of their time on paperwork and administrative tasks, view documentation as the least desirable part of their job, and report higher levels of emotional exhaustion when spending large amounts of time on paperwork (Sheehan & Lewicki, 2016), some providers have resisted implementation of collaborative documentation due to fears that viewing their medical records will be emotionally dysregulating for clients. In a quasi-experimental study initiated in 2010, 20,000 clients were invited to read their physicians notes; of the participants who completed surveys regarding reading of the notes, approximately 99% supported continuation of the practice and reported benefits, such as “increased understanding of their health concerns and improved adherence to treatment plans including medications, as well as a greater sense of involvement and control in their health decisions. Notably, most participants were not worried, confused, or offended by physicians’ comments in the medical records” (Maniss & Pruit, 2018, p.4). In another study by the National Council, of more than 15,000 mental health clients with CD experiences, 82% reported that the practice was “helpful” or “very helpful” when implemented for progress notes, and more than 70% of respondents reported that they would feel favorably toward using CD in the future” (Sheehan & Lewicki, 2016, p.308).
With evidence that clients perceive collaborative documentation as positive, providers can implement this innovative practice to benefit their clients, while also benefiting themselves. Implementation of CD in practice can save providers valuable time and energy, which can be better utilized during direct contact with clients or implementing self-care strategies to support their own mental health. At a large mental health center serving approximately 10,000 individuals in Illinois, providers who implemented CD decreased their documentation time from an average of 11 minutes per client to 3 minutes per client (Maniss & Pruit, 2018); this translates to saving an average of more than five hours of documentation time per week. Furthermore, clinicians who practice CD have described shifting the emphasis in their notes from labeling to describing, which results in more person-centered and non-judgmental language that supports treatment and client’s personal goals (Maniss & Pruit, 2018).
The process of collaborative documentation conveys several messages of empowerment, including “(a) that clients are capable of planning and describing their own treatment; (b) that clients’ words are important enough to use in written documents; (c) that clients have the right and responsibility to review records and correct clinicians; and (d) that clients can cognitively and emotionally manage the information” (Sheehan & Lewicki, 2016, p.310). Collaborative documentation practices are associated with increased client engagement in the therapeutic process, improved outcomes, and increased efficiency and well-being for providers. With the shift in mental health services to a recovery approach, which upholds the client’s values and perspective, an innovative practice such as collaborative documentation is an integral component of today’s mental health services.
Occupational therapy’s belief in the fundamental need and ability to be an agent in one’s own health aligns with the approach of collaborative documentation to empower the client to take charge of her own mental health by becoming an equal partner with the clinician throughout all aspects of the process, such that the client can realize her full potential as a positively contributing member of society.
Sharon Vincuilla, OTR/L
Occupational Therapy Doctoral Resident
Maniss, S. & Pruit, A. G. (2018). Collaborative documentation for behavioral healthcare providers: An emerging practice. Journal of Human Services: Training, Research, & Practice, 3(1): 1-23.
Reilly, M. (1962). The 1961 Eleanor Clarke Slagle lecture: Occupational therapy can be one of the great ideas of 20th century medicine. American Journal of Occupational Therapy, 16(1): 87-105.
Sheehan, L. & Lewicki, T. (2016). Collaborative documentation in mental health: Applications to rehabilitation counseling. Rehabilitation, Research, Policy, & Education, 30(3): 305-320.
Stanhope, V., Ingoglia, C., Schmelter, B., & Marcus, S. C. (2013). Impact of person-centered planning and collaborative documentation on treatment adherence. Psychiatric Services, 64(1): 76-79.
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