• 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?

•When writing 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 name at top of page

• List all other professionals’ names in full & then after this just first name

• be written in consultation with your shift partner

• Be in chronological order• Be brief / summarised• Have good grammar• Be legible• Be factual• Be in paragraphs• Have no line spaces• Be signed and co-signed

• Dated when signed• Not have abbreviations• Be easily understood• Have punctuation• Be initialled where mistakes

have been corrected• Be signed by young person

when read by y.p• Start new page each morning• Include positives• Not have initials (e.g staff

A.K)• Have am / pm or 24 hour

clock

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).