Integrating solution-focused documentation templates into electronic medical records can help create solution-focused fluency, sustain solution-focused practices within organizations, and improve care coordination, communication, and client outcomes. Thanks for reading this article on solution-oriented documentation, which I don't think is the most interesting topic. How did you decide to dedicate your time to working tirelessly on the front lines of the mental health pandemic?Since keeping up with grades is the pathetic bane of our everyday lives? As my colleagues used to say "a rating is just a rating" and "a rating is a good rating" but ratings (documentation) now serve many additional purposes including accountability for third party refunds, accrediting agencies , records of care, providing clinical decision support information, and creating a repository of information for clinical research and quality improvement initiatives.Medical and mental health workers must complete all types of documentation, such as: B. Comprehensive psychological evaluations and ongoing documentation to determine if a client is eligible for counseling, what types of treatment are indicated, formulate treatment plans, coordinate care with multiple providers, documenting when patients are ready to complete individual treatment episodes or “done up” and if a higher level of care is indicated, e.g. in emergencies and crises. However, little empirical attention has been paid to this entry and subsequent paperwork (Richmond et al., 2014) and there is little evidence in the literature to guide the selection of specific data entry methods according to the nature of the data being documented (Wilbanks 2018).
GPs and behavioral health professionals often differ in their reporting requirements, codes, regulations, and language. It is important to work collaboratively with clinical teams to create personalized, solution-focused collaborative models that are unique to each practice context. Allowing professionals within organizations to review their current documentation forms, receive feedback directly from clinicians, and test forms with professionals is critical to successful implementation. Integrating solution-focused questions with semi-structured data entry, narrative text creation, and structured data entry can take advantage of the positive aspects of electronic records (Janet y Yeracaris 2020).
At the end of this article you will find sample documentation focused on solving an admission exam, a progress note with a case study and aSolution-Focused Security Assessment (SFSA).
How solution-focused documentation can help sustain this evidence-based practice (EBP).
Solution-Focused Brief Therapy implies a change of paradigm, order and language. These components can be easily integrated into documentation templates to improve clinician language skills and to support the solution-oriented brief therapy approach in organizations.
Documentation is considered static and immutable; However, what questions are asked, how they are asked, and when they are asked make all the difference in the narrative created. The solution-focused professional seizes hope by helping clients develop a narrative that allows them to acknowledge their agency and resources while developing an action plan for the future. Solution-focused documentation can help clinicians and clients create a hopeful report, while making record-keeping a bit more tolerable and bearable for practitioners.
Solution Focused Brief Therapy (SFBT) is basically talk therapy. Getting closer. The questions are structured to instill confidence in the client while acknowledging their agency, strengths, and resources, and creating a collaborative treatment plan with the client. The questions are designed to help clients articulate what theytimeit worked thatEswork andwhat your best hopes are, that you are confident, and have the necessary skills that are "good enough" to complete defined episodes of treatment.The solution-focused professional seeks to emphasize positive language while instilling conviction and confidence in their client. Solution-focused documentation templates can offer clinicians friendly reminders and encouragement to ask hopeful questions. The questions we ask, what we hear, what we ignore, how we ask the questions, and the order in which we ask them are all important.
Imagine that the following questions were part of a semi-structured electronic record document.
- "What are your greatest hopes?": conveys the assumption thatdohave the best hopes.
- "What was better since the last time we met?: Conveys that something was better and looks for positive differences/exceptions.
- "What is happening that you want to keep happening?"communicates that some things work.
- "What do you know about your condition?": conveys that theydohave knowledge and experience.
- "What do you know about your son so that he can be successful in life?":conveys the belief thatdoThey know their child will be successful.
- “Assume that 1 is that you are confident that your skills are good enough to complete this episode of treatment, and 1 is the opposite; Where are you now?":it conveys that clients have the ability to develop skills and graduate into discrete episodes of treatment.
How Solution-Oriented Documentation Differs from Problem-Oriented Documentation
Traditional admission and follow-up documents are based on a medical model that requires a detailed description of the client's problems. Problem-focused approaches require a thorough understanding of all symptoms in order to diagnose and then treat the client. In stark contrast to this is solution-focused brief therapy (SFBT). SBFT is the only therapeutic modality that does not require a full understanding of the problem in order for the client to achieve their goals. SFBT begins by uncovering a detailed understanding of the client's greatest hope for their future and collectively seeks client-related resources, actions, and courses of action that are based on that perspective. The focus is on detailing what a client iswill servewhen your problem is resolved instead of diagnosing and examining the symptoms. Based on the premise that people have the resources to solve their problems, the SFBT builds on those strengths and abilities by building a common dialect that focuses on whattimeworked andit worksin the life of a client.
Activation of resources and therapeutic interventions that strengthen the client's capacity to act and their abilities play a central role in the success of treatment (Gassmann & Grawe 2006).Therapists who create an environment in which clients perceive that they function well and activate their resources.earlybe more successful in the session (Gassmann & Grawe 2006). Research was conducted to assess problem-focused versus solution-focused intake questions in pre-treatment change and to compare a standard written problem-focused question intake form with a brief therapy-focused intake form. the solution (Richmond 2014). Customers who answered the solution-focused questions reported significantly more solutions and fewer problems than the comparison group. Clients in the SFBT intake interview significantly improved on the outcome questionnaire before their first therapy session, whereas patients in the traditional diagnostic intake did not. This study showed that approval processes are not neutral in obtaining information and that power-based questions have advantages (Richmond 2014).
Example of solution-oriented documentation clinical case:
Below is a brief example of a case and a way to integrate the solution-oriented documentation. Of course, there are many different mandates and requirements; This example contains only one. All documentation templates require input from employees and organizations to ensure they meet the requirements.
Karl is an 18-year-old transgender man (he is the preferred pronoun) who presented to the emergency room after a car accident. He was reportedly texting his friends about a date while driving to hang out when he didn't realize the car had pulled up in front of him. The car was totaled. Karl suffered a broken leg and a back injury. He was hospitalized due to the severity of his injuries and the need for surgery on his leg. While awaiting surgery, Karl reported suicidal thoughts and wishes to die. Karl's father was away the day of the car accident to take care of his elderly parents and had not yet returned home. Karl had a hard time when his father was out of it and had an overdose attempt six months ago while his father was taking care of his elderly parents. Karl's mother died of cancer when Karl was 12 years old, and Karl spent much of his youth witnessing his treatments, his decline, and his death. The following is an excerpt from the evaluation of Karl's seizures during his stay in the hospital's medical department.
Tx: Hi Karl, would you like to be called that?
Tx: Thanks for taking the time to get to know me. My hope is that I will be of use to you. I'll do my best. Is it okay if I ask you a few questions in the hope of helping you? Some questions can be a bit challenging.
TX: Thanks. It must be hard for you to be here; How have you been these last days?
Carl: It was hard. It's noisy and I can never rest. I just want to go home.
TX: Of course. It must be very frustrating for you to be here. What do you know that has helped make things a little more bearable while you're here?
Karl: Get painkillers.
Tx: How did the pain reliever help you?
Karl: It was bad after the accident. I was in great pain. All I could think about was killing myself just to ease my agony.
Discussion: tone setter and trigger functions:
The therapist sets the tone by thanking Karl and confirming what he would like to be called and agreeing to the interview that follows. The therapist also provides many "for you" responses followed by coping questions that activate Karl's individual resources early in the conversation.
Tx: I'm glad the meds are working for you. On a scale of 1 to 10 (10 being the best), how well would you say you tolerate your pain?
Karl: Probably a 5.
Tx: What would be a good enough number?
Tx: What prevents the number from being less than 5?
Karl: I can sleep a little.
Tx: What else prevents you from being smaller?
Karl: From one, and I hope the surgery helps.
Tx: What did you do that helped the drug work, even a little?
Karl: I just try to distract myself by playing video games. The nurses brought me some games and that helps a little.
Discussion: Pain Tolerance Scale
The therapist deals with your pain and how you bear it, taking care of your well-being. The 1-10 scale of how well Karl tolerates pain and how helpful the medication is is a more constructive way of assessing pain. This promotes your ability to act to cope with pain.
Tx: I'm impressed how you handle it. I wonder if you know whose idea it was for me to come see you today.
Karl: I think it was the nurse.
Tx: What do you know that the nurse was worried when asking me to visit you would help you?
Discussion: Exploration of external VIPs
Asking Karl whose idea the therapist came from and framing this as a concern can be helpful in exploring important personalities in Karl's immediate social context. Note that the therapist was not asking "why" but rather what the caregiver was interested in by steering the narrative toward a narrative of caring and compassion.
Carlos: I don't know. (Pause) Probably because I said he wanted to die and couldn't take it anymore.
Tx: What do you mean "wait"?
Karl: My dad is in Arizona and when he gets back he's going to be mad at me. I know he's going to revoke my driver's license and driving to my friends' house is the only thing that makes me feel better.
Discussion: Explore the customer language
Karl was able to identify the reason for the counseling: that he wanted to die. Exploring the meaning of his words provided more insight into Karl's concerns and the reasons for his distress. Paradoxically, while it may appear to slow down the conversation, exploring the client's meaning often makes the conversation move faster as therapist and client negotiate a shared understanding.
Tx: It must be very difficult for you to think about that as you deal with your pain and the upcoming surgery. How did you put up with all this?
Carl: It was hard. My dad is still in Arizona and won't be home until tomorrow.
Tx: Of course it must be difficult for you. Is your father an important person in your life?
carlo: yes I don't know what I would do without him.
Tx: What do you appreciate most about your father?
Karl: He's always there for me, even if I do stupid things. He doesn't give up on me.
Tx: What did he do to always be by your side?
Karl: He and I are close. We went through a lot after my mother died. We help each other.
Tx: It seems that your father loves you very much. If you were to ask him what he appreciates most about you, what would he say?
Karl: That I'm strong and can take a lot.
Tx: What do you mean "manage a lot"?
Karl: My mother died when I was 12 years old and it was very difficult.
Tx: That sounds incredibly challenging. What would your father say you did to deal with it?
Karl: He would say that I still go to school and take care of people, that I am strong.
Tx: What would he say that you are strong?
Karl: That I care about people.
Tx: You two sound very strong. I wonder who else are the important people in your life?
carlos: my mother Although she passed away, I think about her a lot and I know she is with me.
Tx: What do you think your mom appreciates most about you?
Karl: She knows how much my father and I care and help each other. She would be proud of it.
Tx: What else would she appreciate about you?
Karl: I'm not giving up.
Discussion: Exploring VIP
Taking the time to ask who the most important people in Karl's life are and what they value most about him is key to highlighting the values of your relationship. Often it is these meaningful relationships that protect and prevent people from having suicidal thoughts.
Tx: If I were to ask your mom and dad what their best hopes are for you to let them know it's safe to come home, what would they say?
Karl: My father wanted to make sure I didn't do anything dangerous.
Tx: What would he expect from you?
Karl: He would like me to tell him when I am upset and looking for support.
Tx: What else would you say that you can protect yourself?
Karl: That I don't drive and I get into accidents and I want to end my life. I do not want to die; It's just that sometimes I get so angry that all I can think about is the relief of being with my mom.
TX: Of course. These are very intense emotions that you are experiencing. I wonder what are your reasons for living?
Karl: I want to study and become a nurse.
TX: wow. This is impressive. Have you always wanted this or is it different?
Karl: I have wanted to be a nurse for a long time. Since then I see how they have helped my mother and our family.
Tx: Wow, you're strong. Where do you get this determination?
Karl: Probably my father. He doesn't give up. He keeps trying to help his parents and me.
Discussion: Exploring the best hopes
Often, customers experiencing intense emotions are better able to answer what their best hopes are from the perspective of their VIPs. It's even more important that you know who the most important people in your clients' lives are. Karl could easily live up to his parents' best hopes of him: to be on the safe side. After that, every question or answer was focused on activating his resources, including exploring his reasons for living. This is in contrast to the question why he would want to die. Exploring his reasons for living revealed additional resources and opportunities to praise Karl and explore positive differences with him.
Tx: Sometimes I ask you some questions to help you. That would be good?
Tx: Say ten if you are sure you can protect yourself and one is otherwise; Where are you now?
Karl: about a 5.
Tx: And what would be a good enough number?
Tx: What prevents the number from being less than 5?
Karl: Knowing that my dad will be here soon.
Tx: What do you know about your father being here to help you soon?
Karl: I just have to have him around me. He knows how to calm me down.
Tx: What else keeps the number from getting smaller?
Karl: That I wouldn't do anything. I wouldn't want to hurt my father. He would kill him.
Tx: Suppose I ask your father how sure he is of his ability to protect from 1 to 10; what would he say
Carlos: I don't know.
Tx: You know your father best. There is no correct answer. I just wonder what do you think?
Karl: Probably a 3
Tx: What do you think is the reason why your number is 5 and not 3?
Karl: I think I would say that he is afraid that he would crash again and do the same thing a few months ago. She'd probably say she's afraid he's dead.
Tx: Sure, I'm sure it must be scary for him to know that you could have died. What do you think prevents you from knowing that its number is less than 3?
Karl: That I'm here and getting help.
Tx: What else do you think prevents his number from lowering?
Karl: That he's on his way and that he'll be here soon.
Tx: I was wondering Karl, what would you do if your confidence was a little higher, at a 6?
Karl: I would have a plan when I get out of the hospital.
Tx: What do you mean by a plan?
Karl: That my father and I talk and have someone to talk to.
Discussion: Building confidence in the ability to stay safe
Building trust in Karls' ability to stay safe and "balanced" is an effective way to develop a shared safety plan. Even if her parents were not present at the session, it was easy to include her perspective in the conversation. Numbers limit linguistic confusion and allow for a clear plan that progresses in small, manageable increments. Numbers often help clients safely manage the intensity of their experience, as working at scale gives you more opportunities for your agency and plan to stand out. And hope = agency + plan!
These sample documents are provided in PDF format.
Case Study Karl Progress Note
Solution Focused Progress Note
Solution Focused Adult Intake Questionnaire
Solution Oriented Security Assessment Tool
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Richmond, C.J., Jordan, S.S., Bishop, GH, and Sauer, E.M. (2014). Effects of solution-focused versus problem-focused intake questions on pretreatment change.Systemic Therapies Journal, 33(1), 33.
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