Effective Documentation: How to Keep Your Head Above the Water...

Effective Documentation: How to Keep Your Head Above the Water...

Clinical Documentation is an inevitable tedious task that everyone in the mental health world must become familiarized with doing well! It is an essential part of the clinical process, and serve somewhat as a partner and road map for the clinician. It cements the clinical process in history, and guides the evolution of the clinical process from intake to termination.

Clinical Documentation is one of the most discussed topics in clinical supervision, mental health professional social media groups, featured in countless memes adding humor to the profession and drilled into every BA level, graduate and budding clinician alike.

Personally, I believe documentation is a creative art form that conveys a story that when completed appropriately, can be deciphered easily by both the novice and seasoned clinician as well as across multidisciplinary personnel. As a clinical supervisor in California since 2014, I have guided many of my graduate MSW and MFT interns and associates towards honing the craft of effective clinical writing/documentation to solidify themselves as respected professionals in the field of mental health. Yes, respect is attached to the quality of one’s clinical documentation and in some cases, determine the fate of one’s longevity in the mental health field.

Quality Documentation Skills

My definition of quality documentation is one in which the both the professional and the laymen should be able to understand and vividly follow the transition of the clinical process for either professional input and guidance and/or learning. It should covey the same understanding across all professions although each profession would naturally view through their own professional schemas for it to be practical for them.

The following are some of the components I’ve discovered  and have educated my students, interns and associates on that differentiates quality clinical documentation from that not deemed so:

  • Timeliness (could be used in court proceedings): Set them for yourself so that you can have a realistic representation of your progress in completing paperwork.
  • Organization/Flow: How are you getting things done? Are you making lists, or setting apart a number of things to get done in a day. Think about how you are organizing your day and if it's effective. 
  • Grammatical Structure: Are your notes conveying the right message? Have someone read the note, or read it back to yourself out loud.
  • Detailed/Descriptive (Does it capture the story): Are you telling the right story? Are you putting too much or too little details?
  • Conciseness (Straight to the Point without telling too much info maintain confidentiality): Notes are a snapshot, try to get straight to the point!

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