How to Improve Clinical Documentation Practices for Neurodivergent Clinicians

As a clinician, you are responsible for effectively treating your clients. However, one of the most critical aspects of treatment that are often overlooked is clinical documentation. Documentation is vital to clinical practice, as it records the client's treatment history. Proper documentation helps us to track our client's progress and identify areas that need improvement. In addition, it can be used to evaluate treatment effectiveness and make necessary adjustments. For the 3rd annual Therapeutic Applied Geek and Gaming Summit (TAGGS) I was allowed to present a documentation training with co-presenter Dr. Elizabeth Han. On Saturday, April 22, 2023, from 12:30 pm to 2:00 pm, we gave our colleagues a presentation on “Hacking Clinical Documentation for the Neurodivergent Clinician.”

As a neurodivergent clinician, you may face unique challenges in documenting your clinical work. If you missed the presentation, his blog post would hopefully give tips on improving your clinical documentation practices as a Neurodivergent clinician.

Identify Your Strengths and Challenges

As a Neurodivergent clinician, you may have strengths and challenges that are unique to you. It's essential to identify these areas and use them to your advantage. For example, if you have strong visual-spatial skills, you may find it easier to create diagrams or flowcharts to explain complex treatment plans. On the other hand, if you struggle with time management, you may need to set reminders or create a schedule to stay on track.

Neurodivergent clinicians may encounter various challenges in clinical documentation, including:

• Difficulty with time management and prioritization

• Difficulty with attention and memory

• Problem with organization and structure

• Difficulty with written expression

To overcome these challenges, develop coping strategies such as:

• Breaking down documentation tasks into smaller, more manageable steps

• Creating a schedule or a to-do list to manage time

• Using visual aids, such as diagrams or flowcharts, to organize information

• Using templates or checklists to ensure completeness and accuracy

• Seeking feedback and assistance from colleagues, supervisors, or mentors

• Using speech-to-text or text-to-speech software to facilitate written expression

Use Technology to Your Advantage

Technology can be an excellent tool for improving your clinical documentation practices. There are many software programs and apps available that can help you to stay organized and streamline your documentation process. For example, electronic health record (EHR) systems can help you to manage your client's information, create treatment plans, and track progress. Voice-to-text software programs can also transcribe your notes, saving you time and effort.

Develop a System

Developing a system for your clinical documentation can help you stay organized and document all necessary information. This system should include guidelines for documenting your sessions, what information you need, and how you will store and organize your notes. It's essential to make your system as simple as possible so it's easy to use consistently.

Collaborate with Your Team

Collaboration with your team can help ensure that your clinical documentation practices are effective. Your colleagues can provide feedback and support, help you identify improvement areas, and share their best practices. Additionally, collaborating with your team can help you to stay accountable and motivated to improve your documentation practices.

Seek Training and Support

Clinicians benefit from training and support to enhance their clinical documentation practices. Some examples of training and support resources include:

• The recording of our training, “Hacking Clinical Documentation for the Neurodivergent Clinician.”

• Clinical documentation guidelines and best practices, such as those provided by the Substance Abuse and Mental Health Services Administration (SAMHSA) or the National Council for Behavioral Health (NCBH)

• Continuing education courses or workshops on clinical documentation and related topics

• Mentorship or supervision from experienced colleagues or supervisors

• Peer support groups or networks for Neurodivergent clinicians

Use Person-Centered and Strength-Based Writing

Person-centered and strength-based approaches can help develop more effective and efficient documentation practices. These approaches emphasize the client’s perspective and strengths and encourage collaboration and empowerment. Some examples of person-centered and strength-based approaches in the documentation include:

• Using narrative therapy techniques, such as externalizing conversations, to explore the client’s story and goals

• Using motivational interviewing techniques to elicit the client’s motivation and preferences

• Using strengths-based language and framing, such as "challenges" instead of "deficits" or "opportunities for growth" instead of "problems."

Advocate for Accessibility and Inclusion

Sometimes the problem is systemic. Therefore, we must advocate for accessibility and inclusion in clinical documentation practices. Some examples of advocacy actions include:

• Providing feedback to employers or professional organizations on the accessibility and usability of clinical documentation tools and systems

• Advocating for the use of alternative communication methods, such as plain language or visual aids, to improve accessibility and understanding for clients

• Educating colleagues and clients on the needs and strengths of neurodiverse clinicians and clients and promoting a culture of inclusion and respect.

Improving your clinical documentation practices is essential for effectively treating your clients. As a neurodivergent clinician, you may face unique challenges in documenting your work, but there are many strategies that you can use to overcome these challenges. By understanding the importance of documentation, identifying your strengths and challenges, using technology, developing a system, and collaborating with your team, you can improve your clinical documentation practices and provide the best possible care to your clients.

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