Beating the documentation backlog in mental and behavioral health

Documentation is essential to delivering high-quality care. However, the increasing demands on therapists often lead to a documentation backlog, affecting efficiency, patient care, and even your well-being. Don’t panic! Easier said than done, but while your backlog might seem overwhelming, it is something you can overcome. You are not alone!  

Don’t know where to start? We’ve got you covered. This post will help you implement a plan and establish good habits that will help make efficient documentation second nature. Let’s dive in. 

Make a list

First things first: create a list of all the documentation that is missing. Organize it by client and then set priorities. That will allow you to get started and put out fires and set priorities.

Prioritize documentation 

The first step in battling the documentation backlog is to recognize its importance. Allocate dedicated time for documentation daily and ensure that all staff understand its critical role in patient care and reimbursement.  

Chip away every day. Think about the number of documents you need to finish. It’s a scary number. But if you divide it by several days, suddenly it’s not so bad. 

If your backlog is bad, consider taking time off to focus on reducing or eliminating the amount of paperwork you’re behind on. It’s not the greatest feeling to work on “days off”, but you’re less likely to burn out than if you skip breaks and work late hours. 

Stay ahead of your current documentation. Don’t create another backlog by trying to fix one. Stay on top of current documentation, and make sure to finish that first. 

Streamline documentation processes

Implementing efficient documentation processes can be a game-changer when it comes to reducing and avoiding backlogs. To expedite the documentation process, consider electronic health record (EHR) systems that provide user-friendly templates, pre-filled fields, and easy access to patient information.  

Ensora Mental Health provides an intuitive and user-friendly EHR with customizable templates, pre-filled fields, and easy access to patient information. This simplifies the documentation process, allowing you to complete notes quickly and accurately. And because Ensora Mental Health is designed for and by therapists, you get access to tailored documentation that requires less work to fit your needs. 

Delegate and alleviate non-clinical tasks 

Administrative tasks can consume a significant portion of a your time. Offloading non-clinical tasks such as scheduling appointments, managing phone calls, or organizing paperwork to support staff or virtual assistants can free up valuable time for you to focus on patient care and documentation. 

Ensora Mental Health includes robust scheduling tools that can help you manage appointments more efficiently, reducing the administrative burden and freeing up time for documentation. 

It also streamlines the billing and invoicing process, automating insurance claims and payment processing tasks. By automating these administrative tasks, you can devote more time to documentation and patient care. 

Ensora Mental Health’s client portal enables secure communication with clients, allowing them to complete intake forms, communicate securely, and access resources. This can alleviate some of your administrative burdens and contribute to more efficient documentation. 

Use voice recognition technology 

Adopting voice recognition technology can significantly speed up the documentation process. You can dictate your notes or use speech-to-text software to transcribe your thoughts directly into the EHR system, reducing both the time and stress associated with manual data entry. If you want to use this technology during sessions, ask your clients, as you don’t want to record them without their knowledge. 

Implement time management techniques 

You can employ various time management techniques to tackle a backlog effectively. One such method is the Pomodoro Technique, which involves working in short, focused bursts followed by brief breaks. This technique boosts productivity and prevents burnout. 

Some people find it easier to slip into a “focus mode” by listening to music or putting something in the background to signify it’s time to work on notes. Be sure to pick something that lets you focus on notes – you don’t want to be watching a show or switching songs every minute. Instrumental music, lo-fi beats, and video game music are common options.  

Use templates and documentation tools 

Developing and using templates or document management tools can save time and simplify the documentation process. Templates can be customized for specific patient scenarios, evaluations, or treatment plans, allowing you to fill in relevant information and streamline your workflow. If you often create the same document, it’s worth making a template. Take the time to customize it by removing irrelevant fields and formatting it properly; you’ll save way more time.  

Create a list or spreadsheet of frequently used phrases you can copy and paste. You can keep adding and building out your list and organize it with tabs or headers for different diagnostics or documentation (for example, phrases for anxiety or progress notes). Be sure to format fields you need to change to be highly visible when you review your notes, so you still have personalized documentation. 

Leverage Wiley Treatment Planner 

Speaking of documentation tools, Wiley’s Treatment Planner is a valuable resource that can aid you address your documentation backlog and streamline your workflow.  

1. Customizable treatment templates: The Wiley Treatment Planner series provides customizable templates for treatment planning, progress notes, and clinical documentation. By using these templates, you can efficiently organize and document your treatment strategies, reducing the time required for creating comprehensive and personalized plans for your clients.

2. Evidence-based interventions: The treatment planners in the Wiley series offer evidence-based interventions and approaches for a wide range of mental health issues. These resources can help you align your documentation with best practices and industry standards, ensuring that your treatment plans and progress notes are comprehensive and grounded in proven therapeutic techniques.

3. Time-saving documentation tools: By using the pre-written content in the Treatment Planner series, you can speed up the documentation process. The predefined language and structured format of the treatment planners enable you to efficiently document client assessments, treatment goals, and progress, reducing the burden of creating documentation from scratch.

4. Facilitation of collaborative care: The Wiley Treatment Planner series promotes a collaborative approach to treatment planning and documentation. You can use the resources to communicate effectively with other professionals involved in your clients’ care, ensuring that documentation aligns with multidisciplinary treatment approaches and streamlining care coordination.

5. Support for treatment plan adherence: The treatment planners include tools and frameworks to help you monitor treatment progress and ensure adherence to established treatment plans. By using these resources, you can support accurate and up-to-date documentation of your clients’ journeys, helping to streamline the ongoing management of of care.

Invest in EHR training 

Staff must receive proper training on using EHR systems effectively. Many EHR platforms offer training sessions and resources to refine their use. Training can enhance your proficiency, minimize documentation errors, and improve documentation speed. You’d be surprised at how much work you could automate or do more quickly with the right training. If you meet frequent bottlenecks, ask your EHR provider for better ways to work through them. 

Establish documentation policies and protocols 

Setting clear guidelines and protocols for documentation ensures consistency and reduces confusion. Clearly define expectations on the structure, content, and timelines for completing documentation to promote efficient and standardized practices. 

While you need a certain amount of detail, don’t make the mistake of making your documentation too long and too detailed. Review payer requirements to make sure your notes meet reimbursement requirements without having to write for hours.  

Collaborate and communicate 

Encourage collaboration and effective communication among staff. Sharing best practices, documenting tips, or offering peer support can help clinicians learn from each other’s experiences and find innovative solutions to overcome the documentation backlog. 

Some groups even do online sessions where everyone documents together, taking time to bond, keep each other accountable, and ask questions. 

Reflect 

Once you have some time to think and breathe, consider why you fell into a backlog – and what you can do to prevent this from happening again. We’re all human, and sometimes life happens. Don’t beat yourself up over it but implement strategies to make sure you’re not repeating mistakes. Who knows, you might even find yourself with more time to take breaks or think a little.

Your documentation backlog can be a source of stress and anxiety at the moment, but by implementing strategies, like those we’ve covered here, you can chip away until you’re back on track. You can then implement good habits that will keep you on the right path to making documentation typical instead of being a source of anxiety.  

Ensora Mental Health is a comprehensive practice management and therapy notes software designed specifically for mental and behavioral health professionals. It offers a range of features to streamline documentation processes and improve overall practice efficiency. By using Ensora Mental Health’s practice management software and leveraging Wiley, you can access the tools, knowledge, and support they need to streamline your documentation processes, reduce backlog, and ultimately enhance the quality of care they provide to your clients. Start your free 21 day trial, and see you how much faster your notes could be.