Ethical Clinical Report Writing Workshop

1. Ethical Clinical Report Writing Workshop Karen M. Nielsen, Ph.D., RSW (Clinical) Ann Marie Dewhurst, M.A., Reg. Psych. (AB & NWT)

2. Assumptions • Feminist view • Hope-based view • Reports have power that may live beyond the writer. • Reports are part of clinical connection. • Reports have the potential for growth or injury.

3. Approaching Report Writing Consider • Who is your audience • Tone, structure, language • What is your purpose • Focus, goals, • What application your report may have after it leaves your hands.

4. Structuring of Reports Standard information • Title • Date of report • Purpose of report • Relevant referral or client data • Birthdates, age, referral agents, etc. • Request for service statement • Treatment goals for this reporting period.

5. Statement of limitation All reports have limits related to: • Validity of data • Self-report, limited range of sources • Reliability of data • Test results have limited life-span • Generalization of data Therefore, it is important to note this in a report.

6. Application • Write your own statement of limitations as it applies to a specific report you might write.

7. Confidentiality Include where relevant: • Confirmation that issue was addressed • How it was addressed • Cautions issued • Limits of confidentiality • Distribution of report • Ownership of report

8. Application • Write your own statement of confidentiality as it applies to a specific report you might write.

9. Ethics • Does your client recognize him/her self in the report? • Can your client comprehend your report? • Consistency with spirit of FOIP/PIPA • Is your report consistent with the clinical style your client has come to expect? • Does your report reflect your professional ethics?

10. Reporting Data Sources Indicate where you got your data from: • Interviews (with whom, roles, date) • Documents reviewed and source (including that provided by referral source) • Data requested but unavailable • Testing results and authors of other reports to which you have referred • Cite your references when referring to outside sources

11. Application • Write your own template for inclusion of data sources as it applies to a specific reports you may write.

12. Evidenced-Based Reporting • Link your findings to your data • Conclusions must be based solely on evidence presented in your report. • Link your findings to the specific research literature • Situate your findings in the professional literature where appropriate. • Cite references for all tools used.

13. Integration of data and analysis • Have an introduction to complex reports. • Have a structure that follows a logical flow. • Connect themes. • Limit discussion to issues relevant to the purpose of the report. • Omit data irrelevant to the purpose of the report

14. Ethics • Check your report for personal bias • Frustration with client • Hostility toward client • Judgements of client • Disrespectful language • Preferential treatment • Minimization of issues, omissions of data or exaggeration of gains due to feelings about client

15. Ethical Statements of Risk about a client • Clear, deliberate opinion • Specific type of behaviour and likely vulnerable populations • Evidence based estimates • Specific context • Clear circumstances / risk factors • Time limitations of rating

16. Analysis and Summary Statement • Have a summary statement that includes your: • Clinical opinion • Summary of key issues • Summarize treatment gains related to specific goals

17. Avoiding Legal Pitfalls • Stay within your area of expertise. • Stay within the confines of your data. • Own your own opinions. • Stay with the expressed purpose of the report – avoid two birds with one report unless this is your mandate. • Say what you mean and mean what you say. Avoid ambiguity.

18. Important Stuff • Avoid passive language • E.g. it is suggested that… vs. Dr. Ralph wrote in his risk assessment dated 4/5/6 that… • Use simple sentences wherever possible. • Use headings and bullets. • Write in first person. • Write from a clear outline.

19. Progress Report Outline • Standard Information • Title • Date of report • Purpose of report • Relevant referral or client data • Birthdates, age, referral agents, etc. • Request for service statement • Limits of confidentiality • Limits of progress report • Treatment Goals • clinical formulation • agreed to with client • Progress toward goals • Clinical formulation or analysis • your understanding of what your observations mean. • Summary • Recommendations

20. Assessment Outline • Standard Information • Title • Date of report • Purpose of report • Relevant referral or client data • Birthdates, age, referral agents, etc. • Request for service statement • Defining the assessment process • Limits of Confidentiality • Distribution of report • Dates of assessment sessions • Tools and strategies used • Data sources and documentation reviewed • Assessment data and findings • Static and dynamic risk variables (if appropriate) • Statement of risk or summary of findings • Clinical formulation/ clinical opinion • Recommendations

21. Appropriate Recommendations • Realistic (client, system, resources available) • Specific to presenting issue • Flow from analysis presented • Direct future interventions where appropriate • Include need for referrals to other service providers where appropriate

22. Valerian Consulting Ltd. Karen Nielsen & Ann Marie Dewhurst 9412 91st Street Edmonton, Alberta T6C 3P4 Phone: 780-485-5119 Fax: 780-485-5191 valerian@telus.net