CLINICAL REPORT WRITING

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CLINICAL REPORT WRITING

• In Child and Youth Work
• Nancy Brown Brunton

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General Pointers

• All of your notes, regardless of format, are
  legal documents.
• Most agencies prefer black pen for all written
  work never use pencil.
• All written work must be professionally written

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CONFIDENTIALITY

• Be aware of all identifying information, and
  change to protect client privacy
• When documenting an event which involves another
  client, use only initials for the other client
  (ie client and housemate J.S. engaged in a verbal
  altercation over the basketball.)

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CORRECTIONS

• Never use white out on a document!
• If you make an error, draw a single straight line
  though it and initial just above the error.
• Be careful avoid spelling and grammar errors
  (spell check typically uses American spelling
  Canadian words use a u where American ones
  dont, counselling has a double ll in Canada etc.)

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SOLID CLINICAL WRITING

• Avoids complicated statements keep it simple!
• Avoids familiarity professional language is key
• Avoids opinions except in prognosis and
  formulation statement
• Has your written signature on the documentation
• Avoids jargon!!
• Avoids making a diagnosis stick to behavioural
  descriptions

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WHEN WRITING, THINK

• What do you really want to say?
• Could your document withstand a lawyer or judge
  picking it apart?
• What is the audience for the report?
• What is your intent?

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ALWAYS, ALWAYS

• Keep to the point
• Avoid repetition
• Refrain from any slang
• Be professional
• Remember your audience