NEW BEGINNINGS THERAPY




Report writing in clinical settings - Rules of Thumb 25th August 2019



In the last many years I have had to complete 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. Similarly, I had an opportunity to access and liaise with other professionals from social work or other care services attached to local authorities and local government. Through such a vast experience what I have come to understand 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 understandings quite so challenging to my practice to almost continuous re/education. Such experiences have brought about a wealth of comprehension and after a careful integration of indicated competences within my clinical settings, 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  examples of report writing encountered in my professional experience, and that stands for Don’ts and Do's. Another way of thinking about it, it can be summarised as: 

I shall not necessarily assume that what stands as standard/s on various other professional associations and National Health care professions are miraculously extended in practice to all my professional experiences. Same principles exists, but possibility of bad practice do present alongside good practice. So I thought I could share some of my examples from experience, especially since much had been learned though cooperation and understanding different ways of working from other governmental departments. 

Side view example is from HCPCouncil and have been retrieved from https://www.hcpc-uk.org/standards/standards-of-conduct-performance-and-ethics

Below follows my adherence to Ethics:

And this is what I have come across and it had a significant impact on reinforcing don’ts on my own practice and work.

On several occasions I have come across the following:

• Dishonesty;

• Exploitation of a vulnerable person;

• Failure to act in the best interests of service users;

• Serious breaches of a service user’s confidentiality or data protection requirements;

• Discrimination;

• Harassment and Victimisation;

Now, all above are very serious concerns and had been raised accordingly, some without success and some with a hope that perhaps some learning occurred – it certainly has for me in witnessing such concerns and giving that I am writing this article and I do consider it a critical issue.

It is also important to note as to how it helped me understand that individual practice is not simply extended to a way of working but always working within and with a framework of ethical standards and competences. What has been at times a failure to note, in my experience, is that unless such concerns are not acknowledged further down or up the line, then it may well be to say that you adhere to something whereas in fact there is no evidence of that guideline/standard being put in practice. I am certain there are exceptions like with anything, however, I do consider such an issue to be vital to any professional practitioner practicing in a health care environment/setting.

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 that - to my understanding – cannot and should not at any time become a simple prescribed way of reference, but completely absorbed as a way of practice/being as a practitioner. Most of such values are already existent if not cultivated throughout years of practice.

Ethics

Our ethics 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 above in mind stand not as a judgment or a critique but as an observation and 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. It is very difficult to accept that that is not the case in practice and that has been witnessed by me as a professional and it is a professional experience not an opinion.   










































Rules of Thumb: Report writing in clinical settings


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/)









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