Collaborative Depression Care for Pregnant Women, What’s the Role of Documentation?

Collaborative Depression Care for Pregnant WomenUntreated depression during pregnancy can lead to poor nutrition, drinking, smoking, and suicidal behavior in mothers and also result in premature birth of the baby, low birth weight and developmental problems. A study published in Obstetrics & Gynecology (June 2014 issue), the official Publication of the American College of Obstetricians and Gynecologists (ACOG), says evidence-based collaborative depression care intervention at obstetrics and gynecology clinics is feasible, significantly more effective than usual care in enhancing the quality of mental healthcare, depressive and functional outcomes and improving the satisfaction with depression care and can be provided at modest cost. However, documentation plays a major role in turning this into a successful care model. Before exploring this, let’s take a brief look at the collaborative care model.

Collaborative Care Model – An Overview

According to the study, collaborative depression care model comprises a team of mental health specialists who aid site clinicians in patient depression management. Allied health specialists including nurse care managers or social workers serve as depression care managers, whose jobs include providing evidence-based psychotherapy and tracking patient treatment responses, medications, and compliance. The key components of collaborative care models are team management, tracking systems, and weekly structured case reviews with psychiatrist, depression care manager, and site clinician. In this model, communication influences the level of collaboration that exists in relationships among the team members.

Proper Documentation and Enhanced Communication

Collaborative arrangements require communication to build trust and mutual respect and if you want to establish a good relationship with the psychiatrist, depression care manager and site clinician, an appropriate and comprehensive communication plan is inevitable. Standardized clinical documentation can serve as the best communication plan. Clear and consistent records of consultations, psychiatric interviews, information provided to the woman, indications of messages they had understood, patients’ understanding of their risks, and their choices can significantly improve the communication flow between clinicians and those who are involved in the woman’s care.

Since the key decisions are made on the joint accountability of collaborating professionals, the details of all referrals, consultations and decisions should be documented well to avoid any blurring of responsibilities. These records will help them to make sure that nothing is going wrong. It is also required to document whether the patient is following the recommendations of maternity care professionals and what her response is so that the professionals can identify opportunities for improvement or confirm whether their treatment methods are effective. Conflicting opinions may come up regarding the woman’s care due to the complex interactions in the collaborative care model. It is possible to reduce the chance for such issues by properly documenting histories and care plans.

Electronic Health Records (EHRs) system can be considered an effective documentation system for the collaborative care model since it allows quick sharing of documents among collaborating professionals and supports more streamlined care for pregnant women. However, the major risk with this system is that physicians may copy and paste data to save their time and there is a greater chance for making errors while doing this more frequently. A small error that occurs in one document will be propagated quickly to other documents and reach other collaborating professionals to provide them with wrong information. Transcribing physicians’ dictations and utilizing Discrete Reportable Transcription (DRT) technology to insert the transcribed information into appropriate EHR fields is a better option to avoid this issue.

Julie Clements

About Julie Clements

Joined the MOS team in March of 2008. Julie Clements has background in the healthcare staffing arena; as well as 6 years as Director of Sales and Marketing at a 4 star resort. Julie was instrumental in the creation of the medical record review division (and new web site); and has especially grown this division along with data conversion of all kinds.