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The Importance of Documentation

By Phillip Smith, Student at The Academy

Documentation plays a crucial role in any treatment setting. Documentation helps assure continuity of care. There are many important moments in treatment. Proper documentation can help the practitioner to recall those moments. Behaviors and emotions can help tell a story; being able to discover patterns can help to uncover reasons for certain behavior. Documentation is a very simple tool to help any practitioner is unveiling patterns. It can help track the progress in addressing thought patterns and unhealthy behaviors. If a practitioner isn’t utilizing the tool of documentation it would prove to be very difficult to make continual progress on any one area, let alone multiple areas.

Thorough documentation helps to assist the clients subsequent care. It’s important for practitioners, who may serve the client down the line, have proper information. Without meaningful documentation, it would prove difficult for any future practitioner to continue timely progress. As I mentioned earlier, it is important to identify patterns and track the clients progress; if the new practitioner isn’t aware of the knowledge, insight, and progress you have made, it would be a hindrance to any further progress until the practitioner is able to discover and the learn the insight on their own. This is not only a determent to the subsequent practitioners but to your client as well.

In every field, it’s important to minimize as much risk as possible. Documentation is a great tool in protecting against lawsuits and complaints. Documentation help ensure consent and expectations. It helps to tell the narrative for decisions made, and how yourself or the client responded to different situations. In this same manor, it is important to record information that can help support the proper treatment plan and the reasoning for such services. There are many legal and regulatory requirements in this field, and proper documentation helps to maintain compliance. If documentation isn’t up to par it could affect licenses and or accreditation. It would be difficult to defend or explain one’s actions to a licensing board without the supporting documentation.

Any professional is always looking for ways to improve, or a better approach, a more successful course of treatment, or fresh ideas to tackle ongoing problems. Documentation is crucial in achieving these measures. When something is successful it’s important to document the approach and results so it can be replicated. Documentation will help determine if these were isolated results or a possible approach to treatment that could continually produce successful outcomes.

One of the most important issues close to myself is the quality of care. Documentation is the only long term way to assure the quality of care is not only maintained but consistently improved.  If there are problems or issues that are hindrance to providing quality service, it’s important to document it and the progress in rectifying them. When something is identified to be problematic it’s crucial to create effective preventative measures.

Having worked for some time in utilization review documentation is the single most important tool. Documentation helps to determine if services are being productive and should continue. On the flip side, if documentation is lacking it’s next to impossible to defend the continuation of treatment. Many clients rely on insurance to be able to afford treatment and other services. If documentation cannot support the services being provided it is the client who suffers when they no longer can have a means to pay for such services. It’s proven difficult to present a case to continue treatment when there isn’t enough documentation supporting it. Providers want to see the treatment being successful, and if not what is the plan.

Recently, providers have switched from a fee based model, to a performance based fee. What’s so unique about this approach is it takes into account more than a single client. It looks at services provided as a whole. This is important to recognize because documentation is the only way to truly measure results over a long period of time. It’s interesting how much documentation effects. I have multiple discussions with other professionals and personally I feel and practitioner who doesn’t produce accurate and proper documentation is failing their clients. Documentation assures the client is receiving the best possible treatment; it can determine the availability for funds to afford the treatment. Documentation is part of the treatment process itself. If documentation isn’t being done, or is inadequate it’s easy to determine the client isn’t getting the best possible treatment because an integral part of the treatment process isn’t being completed.

Another role documentation plays is the collaboration among team members. Often clients are seen by multiple members of the same team. One team member needs to be able to see what other members have discussed, or begun working on. They need to be able to see what goals the client is working on, and where they are in that process. Every team member has specific specialties and documentation helps assure they can maximize the quality of the services they provide.

To sum everything up, documentation is one of the most vital parts in the course of treatment. It has a vast multitude of purposes. It assures the quality of services rendered, the continuity of care, and protections for the client, as well as the practitioner. It maintains compliance for legal and accreditation purposes. It helps to direct the course of treatments as well the ability to afford such treatments. Documentation plays so and integral part in any practitioner’s process, it would wise to maximize the usefulness of documentation. Documentation is so important in any treatment process; the lack of documentation not only may seem negligible but could quite possible be deemed negligible. It is impossible to plan a course of treatment without proper documentation. It would be able to measure the growth or progress in treatment without solid documentation. It’s unfair to the client, your team members, and any future practitioners.

Another way to look at documentation is to echo the old philosophical question; If a practitioner render services and there is no documentation to support it, did it happen?