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Collaborative documentation in community behavioral health: The impact of shared record keeping of therapeutic alliance

DiCarlo, Robert C. (2017) Collaborative documentation in community behavioral health: The impact of shared record keeping of therapeutic alliance. Doctoral thesis, Northern Arizona University.

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Concurrent collaborative documentation, or simply collaborative documentation, is a form of record keeping whereby the psychotherapist prepares progress notes in a transparent, collaborative manner with the client during the therapy session. In recent years, this emerging clinical record-keeping practice has been promoted as a partial solution to managing time and the copious volume of records mandated by stakeholders in public behavioral health and managed care settings where psychotherapy services are delivered. This is in contrast to the typical method of completing record keeping after the conclusion of the traditional psychotherapy session. Proponents of collaborative documentation reason that the practice saves time, increases clinician capacity to see more clients, and improves compliance with agency productivity and performance standards. Seemingly born out of quality improvement objectives, collaborative documentation does not offer a theoretical rationale for its use as a psychotherapy process tool, and given its embryonic state, there has been little opportunity to empirically demonstrate the mechanisms responsible for outcomes with its use.This research intended to examine the relationship between collaborative documentation and therapeutic alliance factors with the aim of understanding the strengths and limitations of using record keeping to improve outcomes in psychotherapy. Specifically, the relationship between collaborative documentation and the formation and maintenance of the therapeutic alliance was explored. Two community mental health agencies in Northern Arizona were selected to participate based on their documentation practices, and 60 client-therapist dyads at each agency were anticipated to participate at each agency. Participating clients completed the Working Alliance Inventory—Short Form Revised, a psychometrically reliable and valid instrument for measuring alliance. Regrettably, the desired sample size was not achieved and thus the planned statistical analysis was not possible. However, follow-up interviews revealed potential support for the use of collaborative documentation. For example, the practice appeared to improve trust through increased transparency, and created a platform for providing feedback to clients that prompted insights into behaviors and cognitions more quickly than before. Ultimately, therapist comfort level and skills appeared to influence the adoption of a collaborative documentation process. The methodological challenges, implications for collaborative documentation, and recommendations for future research will be discussed.

Item Type: Thesis (Doctoral)
Publisher’s Statement: © Copyright is held by the author. Digital access to this material is made possible by the Cline Library, Northern Arizona University. Further transmission, reproduction or presentation of protected items is prohibited except with permission of the author.
Keywords: Collaborative documentation; Concurrent collaborative documentation; Concurrent documentation; Record keeping
Subjects: B Philosophy. Psychology. Religion > BF Psychology
NAU Depositing Author Academic Status: Student
Department/Unit: Graduate College > Theses and Dissertations
College of Education > Educational Psychology
Date Deposited: 20 Dec 2017 21:39
URI: http://openknowledge.nau.edu/id/eprint/4994

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