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

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.