Ethical Clinical Report Writing Workshop

Karen M. Nielsen, Ph.D., RSW (Clinical)

Ann Marie Dewhurst, M.A., Reg. Psych. (AB & NWT)

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.

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.

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.

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.

Application

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

Confidentiality

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

Application

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

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?

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

Application

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

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.

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

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

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

Analysis and Summary Statement

Have a summary statement that includes your:• Clinical opinion

• Summary of key issues• Summarize treatment gains related to specific

goals

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.

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.

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

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

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

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