CLINICAL REPORT WRITING

1. CLINICAL REPORT WRITING In Child and Youth Work Nancy Brown Brunton

2. 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

3. 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.)

4. 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.)

5. 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

6. 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?

7. ALWAYS, ALWAYS: • Keep to the point • Avoid repetition • Refrain from any slang • Be professional • Remember your audience

8. Thanks This presentation was prepared and has been shared by Nancy Brown Brunton, Professor, CYW Program.