Unexpected Benefit to Quality Clinical Documentation: Improved Communication Between Providers [Show Notes]

Transcript for “Unexpected Benefit to Quality Clinical Documentation” Video

Note: This video is transcribed using AI therefore some errors have occurred in the transcription of this video.

Hi, this is Alex from Stressless Therapist and I wanted to talk a little bit today about an unexpected benefit to having really good clinical documentation and how that’s going to ultimately help your clients’ bottom line and get them better healthcare than maybe even you can provide. What am I talking about? Because the documentation is all about the work that you do with your client, but have you considered how that documentation can impact care outside of your office? We all write these notes and sometimes they’re short and sweet, sometimes they’re super long, and we can wonder if they ever get read.

But there might be times when they’re not. But if you have a client who has maybe complex medical needs or is working with a lot of different medical providers for various things, having quality documentation is going to be an essential turning point for their care because that documentation is essentially going to be used as your communication with other providers. So let me explain a little bit more.

I mean, we all know the benefits of having good quality documentation for our own work, right? It helps us remember what we did, it helps us understand kind of how the symptoms relate to the interventions, it’s a fantastic kind of CYA protecting us from an illegal thing as it discusses why we do what we do. But if we think about it from kind of a multi-disciplinary approach, it helps other practitioners. Now whether that be a primary care physician, it could be a speech therapist, an occupational therapist, a surgeon, a psychiatrist, any type of other professional, it gives them an idea of what is going on in the therapy room.

Right now, there is an art to documenting, right? You want to have enough information so they have a clear picture of what’s happening in the session, what’s the client struggling with, what are the symptoms that they’re presenting with, but you also still want to maintain that privacy because other people variable can be reading this.

So being able to use your notes in a way that is clear, concise, and understandable is going to help that patient communication and ultimately help kind of other providers give their best version of care. It might be easier to kind of explain this with an example, so think of a client who is maybe clinically depressed and you’ve been working with them for a long time using cognitive-behavioral therapy method, but they’re still persistently experiencing signs of depression that they can’t get out of this funk.

So they go to meet with a psychiatrist. Now the psychiatrist doesn’t have as long a relationship with the Earth they might be new, and they’re really going to want to know what is going on, what’s working, what’s not working. So in your intake, in your treatment plan reviews, and your progress notes, whatever they might be reading, it is a wonderful way for them to get a clear understanding of what symptoms the client is presenting with, evidence as to why things are sticking, some barriers that they might be kind of struggling with, and it’s going to help the doctor know more about their lifestyle.

Right. Are they self-medicating with alcohol, and if so, maybe certain medication is not going to be appropriate? Maybe they have to use a lot of heavy machinery for work so that having something that is really drowsy or it’s not going to help them either. Maybe they’re concerned about weight gain and body image, and so that’s important to know so the provider can provide medication that maybe doesn’t have as much weight gain as a side effect, things like that. Another place where that documentation can be really helpful is discharge.

If you have a fantastic discharge summary or if you are transferring to a different mental health provider, having a comprehensive understanding of what worked and what didn’t work is going to help them pick up where you left off and help that client get to an even farther kind of path in their recovery. Now what makes for good documentation in terms of collaboration? You want it to be short and sweet but comprehensive, meaning you want whoever is reading it to be able to look at it within a minute or two and understand clearly what you are trying to say.

Now having some type of system where I like to use a template really can help with that because they can go directly to a certain section, say, for example, symptoms, and know where to look. A medical provider doesn’t really care too much about the interventions. They’re going to really care more about the symptomatology, the barriers, what’s working, what’s not working, but the how that’s kind of your domain. It’s not really theirs. So having something that has that listed out clear and easily is going to be really helpful.

You might do that with bullet points. You might have that in some type of narration. If you’re doing it with the narration now, make sure that you’re using jargon that everyone can kind of understand, including the patient because the patient variable might be reading, doing this too. You don’t want to use too many medical words just in case someone doesn’t know it. You can’t assume everyone knows what you know, especially if they’re in a different field. So having it concise but still comprehensive, right?

You don’t want to skimp on details like the symptoms, the length of time they’ve been experiencing those symptoms. If you have any kind of objective measurements and data that you can use, that’s even better, but having that available to you, which you can then share to them, is really going to be helpful.

I know I went through kind of a lot of information really quickly. I will link to some other blog posts that I hope will give you some more detailed information, things like outcome measures, as well as the blog post that goes over the more detailed link between medical records and that communication style.

And if documenting is a struggle for you, I strongly encourage you to maybe check out the course that I offer on how to create quality documentation but also do it in a time-efficient manner. And I do that through templates, and it’s changed my world, and I hope it’ll be helpful for you too. So I’ll put a link to that down below as well, but that’s it for now. I hope this little tidbit helps, and happy documenting.

Mastering Clinical Documentation With Speed and Efficiency (includes templates) https://www.stresslesstherapist.com/documentation-course

Progress Note Planners (affiliate links)

• The Child Psychotherapy Progress Notes Planner
• The Adolescent Psychotherapy Progress Notes Planner
• The Adult Psychotherapy Progress Notes Planner
• The Severe and Persistent Mental Illness Progress Notes Planner

Treatment Planning Planners (affiliate links)

• The Family Therapy Treatment Planner
• The Complete Adult Psychotherapy Treatment Planner
• The Adolescent Psychotherapy Treatment Planner
• The Addiction Treatment Planner
• The Child Psychotherapy Treatment Planner
• The Couples Psychotherapy Treatment Planner
• The Parenting Skills Treatment Planner
• The Severe and Persistent Mental Illness Treatment Planner
• The Crisis Counseling and Traumatic Events Treatment Planner
• The Co-Occurring Disorders Treatment Planner
• The Family Therapy Treatment Planner
• The Group Therapy Treatment Planner
• The Social Work and Human Services Treatment Planner
• The Suicide and Homicide Risk Assessment and Prevention Treatment Planner
• The Veterans and Active Duty Military Psychotherapy Treatment Planner
• The Juvenile Justice and Residential Care Treatment Planner

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