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