Impact of Collaborative Documentation on Completeness and Length of Clinical Notes in Behavioral Health Settings.

Abstract

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. 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. 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). These findings demonstrate that collaborative documentation influences clinical notes, providing much-needed research about a widely adopted practice in community mental health settings.