New Beginnings Therapy




Report writing in clinical settings - Rules of Thumb 


For the past many years I completed notes, records, assessments, clinical reports, essays etc as both part of specialist training and as a requirement of specialist settings where I provide counselling/psychotherapeutic services. Through such a relative experience what I am now understanding is that most of such report writing is based on strict, similar principles independently of professional body adherence and membership. But that is in theory. In practice, I had to re/educate myself to various understadings. Such experiences have brought about a wealth of comprehension and helped integrating various competences within my clinical setting, I have been able to acquire an easier way of conversing in lay terms to my clients and other allied professionals. There are two distinct dimensions in which report writing is understood at this moment in my professional development: a) continuous development through an adherence to my prescribed memberships and guidelines and that stands for Do’s and b) carefully observing what I have experienced in reading different examples of report writing encountered in my professional experience, and that stands for re/check. Another way of thinking about it is: I will not  assume that what stands as standard on various professional associations and national health care professions are real examples in practice of all my professional experiences. Same principles exists, but possibility of diversified practice presents alongside all practice. So I thought I could share understandings from different ways of working from  government departments.

Examples:

The registrants of Health Care Alliances are part of Health and Care Professions Council ( HCPC) and on their stated standards as part of the ethical framework of their registrants is stated the following:

The standards

• 1. Promote and protect the interests of service users and carers

• 2. Communicate appropriately and effectively

• 3. Work within the limits of your knowledge and skills

• 4. Delegate appropriately

• 5. Respect confidentiality

• 6. Manage risk

• 7. Report concerns about safety

• 8. Be open when things go wrong

• 9. Be honest and trustworthy

• 10. Keep records of your work

Final standard 10 is what came to my attention in particular given that this is what this article is all about. To expand, Standard 10:

Keep accurate records

10.1 You must keep full, clear, and accurate records for everyone you care for, treat, or provide other services to.

10.2 You must complete all records promptly and as soon as possible after providing care, treatment or other services.

Keep records secure

10.3 You must keep records secure by protecting them from loss, damage or inappropriate access.

(https://www.hcpc-uk.org/standards/standards-of-conduct-performance-and-ethics/)

And this is what I have come across on my own practice and work an

 understanding that individual practice is not simply extended to a way of working but always working with a framework of ethical standards and competences. 

My membership association with the British Association of Counselling and Psychotherapy (BACP) has a wealth of information and educational resources as to best competency on similar matters, but more importantly ethics that are based on values, principles and personal moral qualities that underpin and inform the interpretation and application of Our commitment to clients and Good practice.

Values

Values are a useful way of expressing general ethical commitments that underpin the purpose and goals of our actions.

Our fundamental values include a commitment to:

respecting human rights and dignity

alleviating symptoms of personal distress and suffering

enhancing people’s wellbeing and capabilities

improving the quality of relationships between people

increasing personal resilience and effectiveness

facilitating a sense of self that is meaningful to the person(s) concerned within their personal and cultural context

appreciating the variety of human experience and culture

protecting the safety of clients

ensuring the integrity of practitioner-client relationships

enhancing the quality of professional knowledge and its application

striving for the fair and adequate provision of services

Values inform principles. They become more precisely defined and action-orientated when expressed as a principle.

(BACP, https://www.bacp.co.uk/events-and-resources/ethics-and-standards/ethical-framework-for-the-counselling-professions/)

Most notable from all above is how we, as practitioners, are informing our practice through our values becoming (if not already through its nature) a clearly defined way of informing all decision making.

The do’s and don’t’s, with all of the above in mind stand not as a judgment or a critique, but as an observation and a learning of commonalities between different Ethics and Standards of practice of different professions. It seems to me that no matter how they all read as framework, the interest of clients is not only paramount, but at a minimum requirement should stand for respecting human rights and dignity.


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