FIRST PERSON MELODY Collaborative documentation is a practice that serves as a f

Collaborative documentation is a practice that serves as a framework for documenting health records electronically. It involves mental health practitioners and clients documenting during their session together. CD is patient centered by providing opportunities for the client to have input in their treatment process. Patients and providers both gain a clearer understanding of specific goals or concerns when collaborative documentation is used. Additionally, it builds the relationship between professional and client when working together to document progress. Patients feel they can trust their mental health provider more when they also have access to their treatment notes (Matthews, 2020).
A key motivator for team members to use the CD technique is that it reduces the amount of extra time needed after a session. The mental health professional no longer will need to spend time on notes after a session because it will already be complete. It is likely to be more accurate because it is done during the session instead of afterwards or after several sessions.
Matthews, E. B. (2020). Computer use in mental health treatment: Understanding collaborative documentation and its effect on the therapeutic alliance. Psychotherapy, 57(2), 119–128.
Collaborative documentation (CD) is a process that allows clients and clinicians to collaborate in the documentation of Assessment, Service Planning, and progress notes Collaborative documentation is a tool that provides clients with an opportunity to share their input and perspective on services and progress. (Schemelter, 2012). CD supports the patient centered model of integrated care. It allows clinicians to have more time to engage with clients gaining more perspective as progress notes are reviewed and discussed. Collaborative documentation creates a space for clients and clinicians to gain a better understanding of each other’s points of view (Schemelter, 2012). It is essential to learn collaborative documentation techniques in a a multifaceted integrate clinic as it allows clients to provide real time input and gain an understanding about the range of services being provided for them. There are several benefits of CD. Collaborative documentation empowers clients to become more engaged in their treatment by understanding what is in their charts, clarifying information, discussing treatment outcomes, adjusting treatment plans if necessary (GCU, n.d). Because CD integrates documentation as a part of the clinical process, time spent later documented is saved. One way an administrator could increase motivation for utilizing CD accurately with all team members is to provide training and professional development in the CD technique creating a confident transition, while also demonstrating the efficiency of the technique.
This discussion topic was really interesting to research so I will share some of the information I learned about electronic health records and personal experiences using electronic health record platforms. (EHR). According to Definitive Health Care (2022), electronic health record (EHR) is a digital version of a patient’s chart and stores data like patient health history, demographics, diagnoses, notes, etc. Among the various top vendors, three EHRs that rank at the top include Epic Systems Corporation, Oracle Cerner, and MEDITECH (Definitive Health Care, 2022). Epic and Oracle hold an extensive share of the market due to their success in rural and critical access settings. This implies that the programs are easily implemented and work well in areas that may have less an favorable internet/wifi access/capabilities. In addition, these EHR systems are user friendly making it accessible to providers and patients but are also HIPPA compliant in their software. One aspect about these major EHR systems is that major hospitals are using them which implies data can be transmitted/accessed effectively across systems when various providers are involved.
In my place of work, we use NextGen for EHRs. It is generally user friendly and straight-forward. For example, everything is very simple and easy to understand. However, like anything technology driven, it often has glitches or errors that can be a pain to troubleshoot. However, the organization employs an expert on the system that is available to help untangle any issues. This resource has been invaluable to me so I navigate NextGen.

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