Date of Conferral
1-10-2025
Degree
Doctor of Psychology (Psy.D.)
School
Psychology
Advisor
Derek Rohde
Abstract
Observed inconsistencies in clinical documentation are a problem for a behavioral health organization (BHO) serving homeless individuals with mental illness in the southern United States. The purpose of this study was to examine the impact of inconsistent clinical documentation on patient outcomes within the BHO. The Baldrige Excellence Framework was used to examine organizational leadership, strategy, operations, and compliance practices. The chief executive officer, chief operating officer, and lead psychiatric coordinator were interviewed to assess challenges related to clinical documentation. Archival records were also reviewed to gain a comprehensive understanding of the BHO's documentation processes. Three major themes emerged: (a) inconsistent documentation methods across clinicians leading to incomplete and inadequate patient records; (b) barriers to accurate patient documentation due to homelessness and limited access to patient history; and (c) compliance hurdles resulting from the lack of standardized documentation processes, which have led to regulatory violations and financial penalties. These findings may contribute to positive social change by identifying documentation inconsistencies that affect patient safety and care continuity. Standardizing documentation practices could improve service delivery for homeless individuals with mental illness, ensuring accurate and accessible patient information for care providers. Moreover, enhanced compliance with regulatory requirements may safeguard the organization from legal repercussions and improve overall operational efficiency. These improvements may lead to better patient outcomes for homeless individuals and improved organizational accountability for BHOs.
Recommended Citation
Freeman-Hicks, Shawlawn L., "Documentation Challenges and Service Outcomes in Behavioral Health Organizations Serving the Homeless With Mental Illness" (2025). Walden Dissertations and Doctoral Studies. 16922.
https://scholarworks.waldenu.edu/dissertations/16922
