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•   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.
   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?
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.’
‘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
•   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
◦ 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??
•   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
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
•   TIMES

•   PLACES

•   PEOPLE INVOLVED

•   EVENTS / HAPPENINGS
•   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
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
•   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.
   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.
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
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.
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.
•   How do we write professional reports?
•Whenwriting professional reports it is
  important to state only the facts.
   “Johns behaviour towards staff was unacceptable”
   “Tony told Louise that his father hit him”
   “Claire was in good form today”
   “Callum punched the door with his fist”
•   Inappropriate        prompted             retired…
•   Unacceptable         good form            approached
•   Interacted           exposed              banter
•   Negative behaviour   etc..                space
•   Access               appeared             behaviour
•   Addressed            seemed               swore
•   Challenged           spoken to..          declined
•   Hurtful              named
•   Upset                positive behaviour
   “Colm exposed himself to Mary”
   “Kevin was challenged for his
      inappropriate behaviour”
   “Simon was spoken to about
       breaking the bicycle”
•   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!
•   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
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.
Any Questions
   and /or
 Comments…
   www.writeenough.org.uk
   www.residentialforum.com
   www.goodenoughcaring.com
   Communication (Nicky Stanton, McMillan
    Press 1990).

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Professional report writing

  • 1.
  • 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.
  • 18. How do we write professional reports?
  • 19. •Whenwriting professional reports it is important to state only the facts.
  • 20. “Johns behaviour towards staff was unacceptable”
  • 21. “Tony told Louise that his father hit him”
  • 22. “Claire was in good form today”
  • 23. “Callum punched the door with his fist”
  • 24. Inappropriate prompted retired… • Unacceptable good form approached • Interacted exposed banter • Negative behaviour etc.. space • Access appeared behaviour • Addressed seemed swore • Challenged spoken to.. declined • Hurtful named • Upset positive behaviour
  • 25. “Colm exposed himself to Mary”
  • 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.
  • 31. Any Questions and /or Comments…
  • 32. www.writeenough.org.uk  www.residentialforum.com  www.goodenoughcaring.com  Communication (Nicky Stanton, McMillan Press 1990).