2. • To ensure we as professionals are clear on what needs
to be recorded.
• To develop common practice on how we record the
information and what to record.
• To ensure we know why we are recording and who we
are recording for.
• To highlight commonly made errors within recording and
how to reduce this.
3. WHO are we writing reports for and WHY we write
reports?
WHAT do we need to record and WHAT do we not need
to record?
HOW do we record our information on the young
people?
4. The Residential Forum say:
‘Report writing is perhaps not the most interesting of
subjects that staff in residential care homes have to
address yet it becomes of ever increasing importance
not only to good practice but to ensuring that regulatory
and legal requirements are also met.’
‘Providers have to ensure that what is written by their
staff is factual and correct but is suitable for different
audiences namely residents, relatives, the employer, the
regulatory bodies and in some cases the courts.’
5. ‘A report is a communication of information
or advice, from a person who has collected
and studied the facts, to a person who
has asked for the report because he needs
it for a specific purpose. Often the
ultimate function of a report is to
provide a basis for decision and action’
Nicky Stanton, Communication: McMillan Press 1990
6. • A failure to understand why and when the reports will be
used.
• A lack of understanding about what needs to be
recorded.
• Inappropriate / no systems to facilitate good record
keeping and report writing.
• Illiteracy of some staff.
• The blame culture inherent in social care.
• Lack of time.
• Mistrust of what happens to information that is recorded.
• Tick box culture
7. ◦ The young people in our care
◦ Your organisation
◦ Social workers
◦ Gardai
◦ Inspection Service
◦ Health and Safety Officials
◦ Solicitors / Barristers / Judges / Juries
◦ Ourselves and each other??
8. • Provide a record for the young person of their time in the unit
• Contribute to the development, implementation and review of the
plan for the young person
• Identify and respond to the young persons needs
• Help recognise and establish patterns in the young persons life
and / or behaviour
• To support the provision of consistent, high quality care
• To demonstrate that the unit meets regulatory requirements
9. Everything recorded about a young person should
reflect the process of needs established i.e. from the
care plan to daily interactions, as laid out below:
CARE PLAN
Set out by Social Work Department
Reviewed with social worker as to how needs have been met and new pattern of
needs developing
↕
PLACEMENT PLAN
Developed from needs set out in Care Plan
Reviewed and developed from needs recognised for young person
↕
DAILY REPORTS
Focuses on needs set out in care plan and placement plan
Highlights needs and development that should be addressed in above reports
10. • TIMES
• PLACES
• PEOPLE INVOLVED
• EVENTS / HAPPENINGS
11. • We do not need to write in specific times for
everything
• We only record times if it is relevant to the young
persons needs or progress
Care Plan
↕
Placement Plan
↕
Daily Diary
12. Places only need to be recorded if it gives context
to specific behaviour or event.
Places need to be recorded if it is important to
established needs and / or concerns.
Care Plan
↕
Placement Plan
↕
Daily Reports
13. • When should we name people in reports? – particularly
staff members.
• It is not always necessary in daily diaries to say who did
each specific task with young person. For example: it is
not important who told Mary to wash her clothes but
rather record simply that she was told her clothes
needed to be washed.
• It is necessary to record names in incident / SEN reports
for example.
14. Not every part of a young persons day needs to be
recorded.
For example, we do not need to say how many
times Mary went to the toilet unless she has an
enuresis problem.
Care Plan
↕
Placement Plan
↕
Daily diary
Give a brief outline / description of whole events
rather than detailed accounts of every event.
15. Thursday 5/2/11 Staff on Duty: Florence Nightingale 11o/n
Michael Schumacher 11o/n
John—7:30am--------------Florence--------------
John-------8am----------------------------------------------.
Michael-----------10am---------------------John---------------social worker (Mary
O’Neill)-------1pm--------------------Mary------------. Friend (Peter)----
John------3pm----5pm----------------------------------------. Michael---7:15pm-----------
John-----------------------------------------8pm---------------------
Peter---------------------------------------10:20pm--------------------------------
Florence--------. John--------------------------------------------------Michael—
11:30pm-----Florence.
Signed: Michael Schumacher 5/2/11
Co-Signed: Florence Nightingale 5/2/11
16. Summarising
•In summarising we capture all the important parts of what
we have recorded and express them in a short space.
•We are compressing what we have heard, seen or
learned into a short text
•We are stating the main points and leaving out information
that is not essential.
•Involves analysing information and distinguishing
important from unimportant.
•This is done by linking the key points, using sentences or
paragraphs as appropriate.
•Summaries do not include opinions.
17. Care Plan
↨
Placement Plan
↨
Daily Diaries
Reminding ourselves of the content of the above
reports will help to translate large chunks of
information into a few cohesive sentences.
26. “Kevin was challenged for his
inappropriate behaviour”
27. “Simon was spoken to about
breaking the bicycle”
28. • Many words that we commonly use can be interpreted in
many ways.
• It is better to use simple, child friendly language.
• Do not use opinions or words open to interpretation.
• Just say it how you see it – state only the facts!
29. • List only staff first names if • Dated when signed
name at top of page • Not have abbreviations
• List all other professionals’ • Be easily understood
names in full & then after this • Have punctuation
just first name • Be initialled where mistakes
• be written in consultation with have been corrected
your shift partner • Be signed by young person
• Be in chronological order when read by y.p
• Be brief / summarised • Start new page each morning
• Have good grammar • Include positives
• Be legible • Not have initials (e.g staff
• Be factual A.K)
• Be in paragraphs • Have am / pm or 24 hour
• Have no line spaces clock
• Be signed and co-signed
30. Before signing a report it is important:
• that we can read it fully.
• that we agree and fully understand its
content
Therefore reports should be clear, neat and
legible.