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The client record is where it all begins

May 1, 2007
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Better documentation practices can help improve treatment outcomes

The substance abuse treatment system in this country is primarily comprised of community-based treatment and prevention providers, most of them not-for-profit organizations. They increasingly are challenged by more complex clients, workforce turnover, demands for new competencies in evidence-based approaches, and increasing payer expectations to demonstrate outcomes. These issues intersect in the client record. It is the place where we describe the client's needs, how we intend to address them, and how what we have done is contributing to the client's improvement in functioning.

Yet it is no secret that clinicians rarely cite documentation as one of the activities that makes them feel good about what they do. Client record keeping is often incomplete or inaccurate, in part because it tends to be seen as extra work with limited value. After all, data entry requirements typically are duplicative. Information may be required to be entered into the record and also documented in some other way for program reporting purposes. In both cases, the information often cannot be retrieved easily to inform managers about how programs, or individual clinicians, are performing. Performance data frequently are a year or more old before they end up in any form that might assist decision making, which has been likened to driving while looking in the rearview mirror.

In addition, a number of reports on behavioral health workforce issues cite documentation demands as a constraint on productivity and morale. In environments with these burdens, it is difficult for organizational leadership to benchmark service expectations or retain high-quality staff. It is also difficult to inform policy decisions in the absence of current and relevant clinical data.

These workload demands and data retrieval issues have national implications, notably the ability of SAMHSA to demonstrate accountability for mental health and substance abuse block grant expenditures through the National Outcome Measures (NOMs). It is critically important to realize that the “headwaters” for the river of data that flows to state and federal agencies begin with what is documented in the client's record. A good part of the recent discussion between SAMHSA and the states, individually and through national organizations, has focused on states' ability to report these measures. Less attention has been devoted to why outcome measurement is important in the first place—to improve clinical care. For this to occur we need data on progress toward desired outcomes made available to clinicians and programs in a timely way. In turn, this requires that the initial data collected about a client's needs, strengths, and challenges to recovery be captured in a multidimensional assessment, framed in terms of treatment goals, repeatedly evaluated during treatment, and fed back to clinicians and program managers so that they can use the information to enhance what they do.

These challenges led Texas to develop the Behavioral Health Integrated Provider System (BHIPS). The founding vision of BHIPS was simple: to make it easier for clinicians to do a better job (a subset of the vision was to never ask counselors to do something more than once if computers could do it for them). To some degree, doing a better job was defined as ensuring the easiest collection of required clinical information and then making that information immediately available to the counselor. To a much greater degree the goal was to help guide the counselor through the treatment process so the collected information was seen as helpful rather than as a hindrance. We believe that implementing evidence-based approaches requires in-treatment feedback on progress toward goals.

Many of us who started our careers as clinicians have asked, “Do you want me to treat the client or treat the chart?” While the obvious answer is both, the underlying reality is that counselors have not viewed documentation as a value-added activity. In fact, much of what is required up the documentation food chain appears to have been designed by the Department of Redundancy Department. In Texas we have seen this perspective change by using BHIPS. The system walks the counselor and the client through a series of assessment domains. While we heard some initial trepidation about having the client participate in completing the assessment, experience suggests that collaboration yields better information, and it helps establish that both parties have a shared interest in determining what needs to change to make treatment successful.

The assessment issues identified as warranting attention then are populated into the treatment plan. This is a critical aspect of BHIPS—and the clinical process—because it connects a need with an action. The logical next step is that progress notes are tied to the treatment plan's objectives. This creates a gestalt of what the client needs, what we have agreed to do about it, and how our actions support the goals. An online report displays the changes in client scores on various assessment rating scales, providing data to determine if improvements are being realized. The fact that the progress note for a billable service becomes a claim generated to the state for payment with a couple of mouse clicks is frosting on the cake!

Connecting these aspects of the clinical process electronically won't solve all the issues of documentation requirements, quality care, workforce competency, and all the other complex problems from which we seek relief. But it does create a simple but sturdy foundation that helps counselors think through the process of what goes on in treatment and how their actions influence outcomes.