Clinical report writing
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CLINICAL REPORT WRITING. In Child and Youth Work Nancy Brown Brunton. General Pointers. All of your notes, regardless of format, are legal documents. Most agencies prefer black pen for all written work; never use pencil. All written work must be professionally written. CONFIDENTIALITY.

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CLINICAL REPORT WRITING

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Clinical report writing

CLINICAL REPORT WRITING

In Child and Youth Work

Nancy Brown Brunton


General pointers

General Pointers

  • All of your notes, regardless of format, are legal documents.

  • Most agencies prefer black pen for all written work; never use pencil.

  • All written work must be professionally written


Confidentiality

CONFIDENTIALITY

  • Be aware of all identifying information, and change to protect client privacy

  • When documenting an event which involves another client, use only initials for the other client (ie client and housemate J.S. engaged in a verbal altercation over the basketball.)


Corrections

CORRECTIONS

  • Never use white out on a document!

  • If you make an error, draw a single straight line though it and initial just above the error.

  • Be careful – avoid spelling and grammar errors (spell check typically uses American spelling – Canadian words use a u where American ones don’t, counselling has a double ll in Canada etc.)


Solid clinical writing

SOLID CLINICAL WRITING:

  • Avoids complicated statements – keep it simple!

  • Avoids familiarity – professional language is key

  • Avoids opinions – except in prognosis and formulation statement

  • Has your written signature on the documentation

  • Avoids jargon!!

  • Avoids making a diagnosis; stick to behavioural descriptions


When writing think

WHEN WRITING, THINK:

  • What do you really want to say?

  • Could your document withstand a lawyer or judge picking it apart?

  • What is the audience for the report?

  • What is your intent?


Always always

ALWAYS, ALWAYS:

  • Keep to the point

  • Avoid repetition

  • Refrain from any slang

  • Be professional

  • Remember your audience


Thanks

Thanks

This presentation was prepared and has been shared by

Nancy Brown Brunton, Professor,

CYW Program.


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