Electronic Record Keeping and Psychotherapy Alliance: The Role of Concurrent Collaborative Documentation

Practice guidelines and ethical conduct dictate that psychotherapists must document clinical services in the client’s record. Record-keeping guidelines are often framed from the perspective of risk management and continuity of care—a device for protecting the clinician and documenting and tracking outcomes across the therapeutic encounter. Rarely is the practice of documenting clinical services viewed as an agent to improve the emotional bond and collaborative process of the therapeutic alliance. Meanwhile, managed behavioral health care is placing increasing demands on clinicians to remain productive for the agency while providing timely and accurate clinical documentation, compelling organizations to leverage technologies such as electronic health records in novel ways. An emergent approach known as collaborative concurrent documentation, or simply collaborative documentation, is increasingly being applied by Managed Behavioral Health-care Organizations to expand billable service time, improve productivity, reduce clinician feelings of stress, and allow clients to feel confident as active participants in creating and maintaining their own health records. Proponents extol the approach for its ostensible benefits to both the organization and clients; however, the practice of collaborative documentation has no known empirical basis in the professional literature. This chapter seeks to explore the theoretical assumptions presumed to underlie collaborative documentation in order to lay a foundation for future empirical research on the use of collaborative documentation as a mechanism for improving psychotherapy outcomes.