Silver School of Social Work, New York University, New York City (Yoo, Baslock, Stanhope); Graduate School of Social Service, Fordham University, New York City (Matthews).
Psychiatr Serv. 2024 Feb 1;75(2):186-190. doi: 10.1176/appi.ps.20230118. Epub 2023 Aug 2.
This study aimed to examine differences in community mental health visit notes before and after initiation of collaborative documentation, a practice in which clinicians and consumers jointly document clinical encounters.
Using a clinical informatics approach, the authors sampled visit notes (N=1,875) from nine providers in one mental health clinic. The authors compared notes from before and after the implementation of collaborative documentation by using fixed-effects regression models, controlling for therapist-level effects.
Significant changes in visit note structure were found after the implementation of collaborative documentation. Most sections (N=6 of 10) contained more information (i.e., higher word and character counts) after collaborative documentation implementation, but sections describing a client's feelings were less likely to have any content (OR=0.01, p<0.001).
These findings demonstrate that collaborative documentation influences clinical notes, providing much-needed research about a widely adopted practice in community mental health settings.
本研究旨在考察协作式记录实施前后社区心理健康就诊记录的差异，协作式记录是指临床医生和患者共同记录临床就诊情况的一种做法。
研究人员采用临床信息学方法，从一家心理健康诊所的 9 名提供者中抽取就诊记录（N=1875）。研究人员使用固定效应回归模型，控制治疗师层面的影响，比较协作式记录实施前后的记录。
实施协作式记录后，就诊记录的结构发生了显著变化。大多数部分（N=10 个部分中的 6 个）包含更多的信息（即更高的单词和字符数），但描述患者感受的部分更不可能有任何内容（比值比=0.01，p<0.001）。
这些发现表明，协作式记录会影响临床记录，为社区心理健康环境中广泛采用的实践提供了急需的研究。
