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Considerations for Collaborative Documentation: Before You Start

     In a previous blog, I introduced the concept of collaborative documentation – basically, involving your client in the progress note-taking process.  Before you change to using collaborative documentation, there are a few aspects of it you will want to consider.

     First, the notes we as counselors take make up the client’s chart and that this information is a way to communicate with the client, too.  This is the client’s therapeutic treatment, so the client has a right to be engaged in it.

     Next, as the clinician, collaborative documentation will involve hearing the client’s perspective on the therapy session – and it may differ from your own as the clinician.  The goal is to improve the client’s engagement in the therapeutic process, and to allow the client some involvement in their treatment.  This may – and probably will – lead to the client being more compliant and more likely to achieve positive outcomes.

     A third point to consider is that clinical documentation is really meant to be clinical work; it is a part of the clinical work that is undertaken with the client.  However, when engaging a client in this part of the counseling process, it will be important to use language that the client can relate to in order to avoid any labeling or negative views of treatment.

     Lastly, the clinician will need to re-think the structure of the counseling session, saving the last few minutes (10 to 15 minutes) to engage in collaborative documentation.  It will be important to have a structure for this, and the next blog posts will show how to use the STEPnotesTM format to help clinicians have an organized and structured way to engage in collaborative documentation.


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