Clinical documentation generates a strong emotional response from many clinicians in behavioral health organizations because the requirements are often excessive. Note writing was established to provide a historical record, a means of tracking progress, and a method to coordinate care between current and future providers. Over time, regulators and funders imposed additional requirements, so that clinical documentation now demands significant operational and workforce resources that divert from service delivery. Providers are often compelled to adhere to new requirements and document to excess, leading to wasted time and resources. Poorly designed or outdated electronic health records and technological problems limit staff efficiency and productivity. Staff are pulled from clinical practice to focus on documentation compliance. This limits staff motivation and can lead to frustration, low morale, and burnout.
Leaders must establish systems that balance the critical need for documentation with a supportive and clear context, which removes unnecessary requirements and minimizes changes. They need to ensure that staff appreciate the benefits and protections of documentation for the organization, as well as its value and impact on clients’ lives. Leaders must avoid simply demanding compliance, and instead teach, train, coach, and support staff to master the necessary skill sets.