Ethical Clinical Report
Writing Workshop
Karen M. Nielsen, Ph.D., RSW
(Clinical)
Ann Marie Dewhurst, M.A.,
Reg. Psych. (AB & NWT)
Assumptions
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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
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What is your purpose
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What application your report may have
after it leaves your hands.
• Focus, goals,
Structuring of Reports
Standard information
 Title
 Date of report
 Purpose of report
 Relevant referral or client data
•
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Birthdates, age, referral agents, etc.
Request for service statement
Treatment goals for this reporting period.
Statement of limitation
All reports have limits related to:
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Validity of data
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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
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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
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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
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Link your findings to your data
• Conclusions must be based solely on
evidence presented in your report.
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Link your findings to the specific
research literature
• Situate your findings in the professional
literature where appropriate.
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Cite references for all tools used.
Integration of data and
analysis
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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
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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
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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
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Have a summary statement that includes
your:
• Clinical opinion
• Summary of key issues
• Summarize treatment gains related to specific
goals
Avoiding Legal Pitfalls
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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
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Avoid passive language
• E.g. it is suggested that… vs. Dr. Ralph wrote
in his risk assessment dated 4/5/6 that…
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Use simple sentences wherever
possible.
Use headings and bullets.
Write in first person.
Write from a clear outline.
Progress Report Outline
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Standard Information
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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
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clinical formulation
agreed to with client
Progress toward goals
Clinical formulation or analysis
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your understanding of what your observations mean.
Summary
Recommendations
Assessment Outline
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Standard Information
• Title
• Date of report
• Purpose of report
• Relevant referral or client data
•
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•
Birthdates, age, referral agents, etc.
Request for service statement
Defining the assessment process
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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
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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
valerian@telus.net