Professional report writing


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Professional report writing

  1. 1. • To ensure we as professionals are clear on what needs to be recorded.• To develop common practice on how we record the information and what to record.• To ensure we know why we are recording and who we are recording for.• To highlight commonly made errors within recording and how to reduce this.
  2. 2.  WHO are we writing reports for and WHY we write reports? WHAT do we need to record and WHAT do we not need to record? HOW do we record our information on the young people?
  3. 3. The Residential Forum say: ‘Report writing is perhaps not the most interesting of subjects that staff in residential care homes have to address yet it becomes of ever increasing importance not only to good practice but to ensuring that regulatory and legal requirements are also met.’ ‘Providers have to ensure that what is written by their staff is factual and correct but is suitable for different audiences namely residents, relatives, the employer, the regulatory bodies and in some cases the courts.’
  4. 4. ‘A report is a communication of informationor advice, from a person who has collected and studied the facts, to a person whohas asked for the report because he needs it for a specific purpose. Often the ultimate function of a report is to provide a basis for decision and action’ Nicky Stanton, Communication: McMillan Press 1990
  5. 5. • A failure to understand why and when the reports will be used.• A lack of understanding about what needs to be recorded.• Inappropriate / no systems to facilitate good record keeping and report writing.• Illiteracy of some staff.• The blame culture inherent in social care.• Lack of time.• Mistrust of what happens to information that is recorded.• Tick box culture
  6. 6. ◦ The young people in our care◦ Your organisation◦ Social workers◦ Gardai◦ Inspection Service◦ Health and Safety Officials◦ Solicitors / Barristers / Judges / Juries◦ Ourselves and each other??
  7. 7. • Provide a record for the young person of their time in the unit• Contribute to the development, implementation and review of the plan for the young person• Identify and respond to the young persons needs• Help recognise and establish patterns in the young persons life and / or behaviour• To support the provision of consistent, high quality care• To demonstrate that the unit meets regulatory requirements
  8. 8. Everything recorded about a young person should reflect the process of needs established i.e. from the care plan to daily interactions, as laid out below: CARE PLAN Set out by Social Work DepartmentReviewed with social worker as to how needs have been met and new pattern of needs developing ↕ PLACEMENT PLAN Developed from needs set out in Care Plan Reviewed and developed from needs recognised for young person ↕ DAILY REPORTS Focuses on needs set out in care plan and placement plan Highlights needs and development that should be addressed in above reports
  10. 10. • We do not need to write in specific times for everything• We only record times if it is relevant to the young persons needs or progress Care Plan ↕ Placement Plan ↕ Daily Diary
  11. 11. Places only need to be recorded if it gives contextto specific behaviour or event.Places need to be recorded if it is important toestablished needs and / or concerns. Care Plan ↕ Placement Plan ↕ Daily Reports
  12. 12. • When should we name people in reports? – particularly staff members.• It is not always necessary in daily diaries to say who did each specific task with young person. For example: it is not important who told Mary to wash her clothes but rather record simply that she was told her clothes needed to be washed.• It is necessary to record names in incident / SEN reports for example.
  13. 13.  Not every part of a young persons day needs to be recorded. For example, we do not need to say how many times Mary went to the toilet unless she has an enuresis problem. Care Plan ↕ Placement Plan ↕ Daily diary Give a brief outline / description of whole events rather than detailed accounts of every event.
  14. 14. Thursday 5/2/11 Staff on Duty: Florence Nightingale 11o/n Michael Schumacher 11o/nJohn—7:30am--------------Florence--------------John-------8am----------------------------------------------.Michael-----------10am---------------------John---------------social worker (MaryO’Neill)-------1pm--------------------Mary------------. Friend (Peter)----John------3pm----5pm----------------------------------------. Michael---7:15pm-----------John-----------------------------------------8pm---------------------Peter---------------------------------------10:20pm--------------------------------Florence--------. John--------------------------------------------------Michael—11:30pm-----Florence. Signed: Michael Schumacher 5/2/11 Co-Signed: Florence Nightingale 5/2/11
  15. 15. Summarising•In summarising we capture all the important parts of whatwe have recorded and express them in a short space.•We are compressing what we have heard, seen orlearned into a short text•We are stating the main points and leaving out informationthat is not essential.•Involves analysing information and distinguishingimportant from unimportant.•This is done by linking the key points, using sentences orparagraphs as appropriate.•Summaries do not include opinions.
  16. 16. Care Plan ↨ Placement Plan ↨ Daily DiariesReminding ourselves of the content of the above reports will help to translate large chunks of information into a few cohesive sentences.
  17. 17. • How do we write professional reports?
  18. 18. •Whenwriting professional reports it is important to state only the facts.
  19. 19.  “Johns behaviour towards staff was unacceptable”
  20. 20.  “Tony told Louise that his father hit him”
  21. 21.  “Claire was in good form today”
  22. 22.  “Callum punched the door with his fist”
  23. 23. • Inappropriate prompted retired…• Unacceptable good form approached• Interacted exposed banter• Negative behaviour etc.. space• Access appeared behaviour• Addressed seemed swore• Challenged spoken to.. declined• Hurtful named• Upset positive behaviour
  24. 24.  “Colm exposed himself to Mary”
  25. 25.  “Kevin was challenged for his inappropriate behaviour”
  26. 26.  “Simon was spoken to about breaking the bicycle”
  27. 27. • Many words that we commonly use can be interpreted in many ways.• It is better to use simple, child friendly language.• Do not use opinions or words open to interpretation.• Just say it how you see it – state only the facts!
  28. 28. • List only staff first names if • Dated when signed name at top of page • Not have abbreviations• List all other professionals’ • Be easily understood names in full & then after this • Have punctuation just first name • Be initialled where mistakes• be written in consultation with have been corrected your shift partner • Be signed by young person• Be in chronological order when read by y.p• Be brief / summarised • Start new page each morning• Have good grammar • Include positives• Be legible • Not have initials (e.g staff• Be factual A.K)• Be in paragraphs • Have am / pm or 24 hour• Have no line spaces clock• Be signed and co-signed
  29. 29. Before signing a report it is important: • that we can read it fully. • that we agree and fully understand its contentTherefore reports should be clear, neat andlegible.
  30. 30. Any Questions and /or Comments…
  31. 31.  Communication (Nicky Stanton, McMillan Press 1990).