Challenges in clinical documentation


Group Supervision: Clinical Documentation Skills


Clinical documentation is a crucial part in the practice of psychology. In some parts of the world, it is a legal requirement to keep adequate clinical documents. However, it is not only the fact that it is a legal requirement that makes it an important act. There are many aspects in the practice of the profession that requires adequate documentation. The process of clinical documentation has some positives and some negatives that the practitioners encounter. For example, most documents are prepared and stored manually hence increasing the probability of human errors. This study is going to look at the strengths and challenges encountered by practitioners during the process of clinical documentation and how to overcome those challenges.

Challenges in clinical documentation

Most of the information that requires documentation or coding is done better manually since there has been no proper automatic equipment that can be used to assist in the recording process. This has highly increased the probability of human error during patient information documentation. The paper based process does not assist in increasing efficiency and increases the probability for human error. However, this challenge can be overcome by using automatic data recording methods that will increase efficiency in processing and storage of clinical document (Zuckerman, 2008). On the other hand, some of the clinical documents are complex and require expert knowledge in analysis to avoid the probability of mismatching or confusing patient and process data (Wiger, 2005).

This can also be avoided by automating the clinical documentation process. Documents could be stored using unique keys that help in ensuring that the practitioner does not confuse patient records and treatment procedures. Accuracy is also in demand when recording medical procedures and patient details. This is because, such information is crucial when it comes to making payments and other claims. If this information is not accurately recorded, it may result to complications during settling claims or demanding payment from patients. On the other hand, this inaccurate information may mislead other practitioners. This can be avoided by ensuring that he documents are revised from time to time to ensure that they are up to the set standards. Familiarizing oneself with the documents also plays a central role in reducing the probability for errors.

Strengths in clinical documentation

A huge part of clinical documentation requires collecting information from patients. The forms require patients to give the practitioner information about their condition and descriptive data. Most of the patients are cooperative. This makes it easy to complete documents that require individual patient information. The profession has also made it easy to gather adequate information about individual patients (Zuckerman, 2008). This is by ensuring that even data for patients who are not able to communicate properly is availed. This is through a guardian or a family member who is close to the patient and has enough information about the patient’s condition and details. This plays a central role in ensuring that no detail is left out in recording patient details. This plays a central role in increasing the accuracy and reliability of clinical documents (Wiger, 2005).

Works cited


Wiger, D. (2005). The Clinical Documentation Sourcebook: The Complete Paperwork Resource

For Your Mental Health Practice; John Wiley & Sons


Zuckerman, E. (2008). The Paper Office, Fourth Edition: Forms, Guidelines, and Resources to

Make Your Practice Work Ethically, Legally, and Profitably; Guilford Press



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