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Brief Reports
Published Online: 2 August 2023

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

Nari Yoo, M.A., Elizabeth Matthews, M.S.W., Ph.D., Daniel Baslock, M.S.W., and Victoria Stanhope, M.S.W., Ph.D. [email protected]Authors Info & Affiliations
Publication: Psychiatric Services
Volume 75, Number 2
https://doi.org/10.1176/appi.ps.20230118
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Abstract

Objective:

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.

Methods:

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.

Results:

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).

Conclusions:

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

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Information & Authors

Information

Published In

Go to Psychiatric Services
Go to Psychiatric Services
Psychiatric Services
Volume 75 • Number 2 • February 01, 2024
Pages: 186 - 190
PubMed: 37528697

History

Received: 8 March 2023
Revision received: 8 May 2023
Revision received: 10 June 2023
Accepted: 14 June 2023
Published online: 2 August 2023
Published in print: February 01, 2024

Keywords

  1. Community mental health
  2. person-centered care
  3. Clinical documentation
  4. Collaborative documentation

Authors

Affiliations

Nari Yoo, M.A.
Silver School of Social Work, New York University, New York City (Yoo, Baslock, Stanhope); Graduate School of Social Service, Fordham University, New York City (Matthews).
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Elizabeth Matthews, M.S.W., Ph.D.
Silver School of Social Work, New York University, New York City (Yoo, Baslock, Stanhope); Graduate School of Social Service, Fordham University, New York City (Matthews).
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Daniel Baslock, M.S.W.
Silver School of Social Work, New York University, New York City (Yoo, Baslock, Stanhope); Graduate School of Social Service, Fordham University, New York City (Matthews).
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Victoria Stanhope, M.S.W., Ph.D. [email protected]
Silver School of Social Work, New York University, New York City (Yoo, Baslock, Stanhope); Graduate School of Social Service, Fordham University, New York City (Matthews).
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Notes

Send correspondence to Dr. Stanhope ([email protected]).

Competing Interests

The authors report no financial relationships with commercial interests.

Funding Information

This work was funded by the Constance and Martin Silver Center on Data Science and Social Equity at New York University.

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