Implementing collaborative documentation in outpatient behavioral health

Person-centered care improves service engagement and retention among individuals with behavioral health challenges, but barriers to feasibility often prevent person-centered strategies from being effectively integrated into routine treatment. Collaborative documentation (CD), where providers complete visit notes jointly with clients during session, is designed to be a flexible and time-efficient person-centered practice that may address persistent challenges to adopting person-centered care. To date there is no work exploring the implementation of CD in behavioral health. This study utilized normalization process theory, a leading implementation framework, to understand the process of adopting CD in one outpatient behavioral health clinic.

Focus groups with 22 providers evaluated barriers and facilitators to implementing CD following an organizational CD training. Rapid qualitative methods were used to analyze audio-recorded data.

Whether providers viewed CD as a documentation strategy or as a person-centered practice shaped how it was implemented in routine care. Providers also highlighted the cognitive burden of real-time documentation as a barrier to CD implementation. The presence of organizational champions facilitated provider buy-in and increased adoption, though sustainability strategies were needed to support this in the long term.

Findings highlight the need to better articulate the core elements of CD and achieve a unified vision of practice principles and goals, including its connection to person-centered care. In addition, basic documentation training for providers is needed to increase the feasibility of CD. (PsycInfo Database Record (c) 2025 APA, all rights reserved).