Chapter 29 – Paul Hogan (D2SOP6)

Introduction 

Social care workers write reports and record information every day and in various formal practical situations. Report writing is a skill that we are expected to have from the beginning of our placement or employment, and yet there is little training or direction available, and many social care workers struggle with the challenge of writing reports.

This chapter aims to address this gap by providing an overview of report writing and record keeping for the social care worker in Ireland. The chapter is not prescriptive, but it endeavours to enable social care workers and students to understand and develop the proficiency to write effective, objective and accurate reports and records.

The ability to write clearly, accurately and objectively is an essential skill for all social care workers. It underpins quality service delivery, effective inter-agency collaboration, and best practice in terms of professional development.

This chapter will support students and social care workers to understand this proficiency and develop skills in preparing factual, structured and concise reports to serve various needs and groups. The first section will detail the purpose of effective report writing, followed by the application of a skills model before concluding with a case study. The last section gives some tips for practice educators.

The Purpose of Effective Report Writing 

The purpose of report writing is to provide a permanent and evidenced account of a service user’s development while in care. Reports can also be a tool for staff in person-centred planning. While supporting continuity and cohesion of practice by meeting regulatory and statutory requirements, report writing and record keeping also promotes accountability and transparency in delivering interventions. Effective report writing and record keeping also fosters a lifelong learning environment and contributes to the continuing professional development of social care workers. The Standards of Proficiency for Social Care Workers (2017) set out the expected standards for social care professionals who are regulated by CORU. This comprehensive report determines the standard to maintain competence and performance in producing clear, concise, accurate and objective documentation under proficiency six of the Communication, Collaboration and Teamworking domain.

The ability to produce clear, concise, accurate and objective documentation is a key social care work proficiency, but one in which students receive little formal training and preparation (Webber 2015). Reports and records that social care workers need to produce include assessment reports, daily case reports, family communication plans, access reports, care plans, daily diaries and reflective practices, etc. The social care sector is developing a growing reputation for increased administration, resulting in greater demands for social care workers to master the skill of writing reports. It is also important to be familiar with the organisation’s in-house policy on key tasks such as report writing, safeguarding, data protection and referrals to other statutory, regulatory and professional bodies such as Tusla, HIQA, An Garda Síochána, and members of the legal profession.

Although this chapter does not expand on legislative requirements in relation to report writing, it is important to be mindful of the statutory provisions under, for example, the Freedom of Information Acts 1997, 2003 and 2014; the Data Protection Acts 1988 and 2003; the General Data Protection Regulations 2018; and the Criminal Justice (Withholding of Information on Offences Against Children and Vulnerable Persons) Act 2012. Effective report writing involves good communication skills, having an active rather than passive voice and learning to write objectively. These three important skills are essential for effective report writing.

Good Communication Skills 

The ability to communicate effectively is an integral element of the ability to write good reports and it is an essential part of the role of the social care worker. There are various methods of communication, including oral, non-verbal, and written. The accuracy of the written report is essential as it may inform future interventions and resources for the service user. There is a requirement for social care workers to ensure that what they write is legible, accurate, clear and objective.

When writing reports, it is important to be aware of non-verbal communication and the need to document these in report writing. These may present as shrugs, nods, crossing arms or legs or both, grimaces, gestures, tone of voice and eye contact (Griffiths 2010). Learning to take account of these reactions is part of developing the skills of report writing and record keeping.

A report can be understood as a means of communicating an account, information or advice from a person who has collected the facts to a person who has requested the information for a specific function or the performance of a particular task (Stanton 1990). It is a short, concise document that is written for a particular purpose and a specific audience or multiple audiences, and which generally sets out and analyses a particular situation. There are three basic elements to writing reports in social care: a rights-based and service-user focus; a sound understanding of the values and principles that underpin social care practice; and competence and proficiency in compositional, rhetorical and technical writing skills (McDonald et al. 2015). Reports should be underpinned by social care values and principles such as social justice, partnership and equality while deploying anti-discriminatory, objective and non-judgemental language, which clearly details fact rather than feelings or opinions.

Social care workers must ensure that nothing contained in a report can be interpreted or construed as insulting, abusive, prejudiced, racist, sexist, ageist or discriminatory in any way. Social care workers’ reports must be anti-oppressive, concise, specific and written in plain English to enable greater understanding by multiple readerships. Report writers must ensure that what they write is not only accurate, objective and correct but that it will be understood by various audiences, such as service users, families, service providers, regulatory bodies and, in some cases, the courts. In this regard, it is important to keep the language simple and reader-friendly.

Active Voice versus Passive Voice 

Essentially, there are three main components in a sentence – the subject, the verb and the object. The subject is sometimes called the ‘naming part’ of the sentence. It identifies the person, group or thing performing the action. The subject is most often a noun, pronoun or noun phrase. The verb, or dynamic verb, denotes the action or doing word. It describes what the subject has done or is doing. The object describes the person, place or thing that receives the action of the verb.

‘Active’ and ‘passive’ voice refers to the use of the verb in a sentence. One of the most common mistakes in report writing is using the passive voice, which makes sentences verbose, less concise and less clear.

In the active voice, the action comes before the object. In the passive voice, the object comes before the action. The active voice emphasises the subject, i.e. the person who is performing the action. The passive voice emphasises the object, i.e. the person or thing the action is done to.

The Challenge of Writing Objectively in a Caring Role 

Writing objectively in reports means writing about facts, not opinions. Many social care workers find it challenging to write objectively in a caring role. It is good practice to write reports in an impersonal tone and avoid using judgemental, prejudicial or emotional language. Social care workers should also ensure that they are aware of their own perceptions and biases when compiling reports.

As social care workers are motivated by the emotional, relational, interpersonal and social dimensions of their work, it can be challenging to write documentation that disengages these subjective aspects of the social care role in order to prepare an objective account about a particular occurrence. There is also a fear that an objective account of an incident could be misinterpreted. This is a challenge. Even when we all see the same thing we can each interpret it differently.

To ensure objectivity and clarity, it is important to plan the content of a report and to use correct grammar, spelling and punctuation. Unnecessary details should be omitted. The report writer should not offer diagnoses (unless qualified to do so). Inaccurate or misinformed reports can have consequences for the service user in terms of subsequent decision-making and other interventions.

Effective Report Writing 

A report can be viewed as a reflection on professional credibility. Therefore, it is imperative that a social care worker writes effective reports and documentation.

When writing a report:

• Organise your thoughts.
• Make sure you know the purpose of the report.
• Lay out the information and determine the format.
• Decide on your writing style.
• Use clear, simple English that is easy to read.
• Keep sentences brief and concise.
• Avoid words that are open to interpretation.

Barriers to effective report writing:

• Lack of understanding of the organisation’s policies.
• Being unsure or unclear about what information is relevant or necessary.
• Varying levels of competencies, abilities and expertise among staff.
• Ineffective time management.
• A tick-box culture.
• Rushing to complete reports after a long shift.
• Perception and interpretation.

Reports are necessary for a range of reasons and it can be difficult to ascertain what a good report looks like in all situations (Bogg 2015). However, there are some universal points that a social care worker should apply:

• The purpose of the report is clear.
• The report is written in appropriate language.
• The report is concise.
• The report sets out relevant frameworks and criteria being adhered to.
• The report is proofread to check for any errors.
• The report is signed and dated. (Bogg 2015)

Effective report writing should answer the following:

• Date and time?
• Who was present?
• Where did it occur?
• What happened?
• Did you observe triggers?
• What actions were taken?
• Who conducted the debrief?
• What follow-up, if any, was identified?
• Was the in-house policy referred to?
• Was it necessary to seek advice from line management?

Effective report writing should never contain the following:

• Humour or jokes.
• Colloquialisms such as ‘lost the plot’, ‘went berserk’, ‘had the craic’.
• A diagnosis of the service user – unless you are qualified to make one.
• Discriminatory language.

Useful verbs, terms and phrases:

• It appears
• It seems
• It was decided
• It was recommended
• In particular
• After
• Subsequently
• Consequently
• Although
• Even though
• Displayed
• Became
• Noticed

A Model for Report Writing

Good planning underpins good report writing. You will write a clear, concise and objective report if you take the time to plan what will be in the report and why. It is important that there is a clear sequence of information and the paragraphs are presented in a cohesive and coherent manner with clear links from section to section. The formal nature of report writing for assessments, case reports, access reports, care plans and reflective practices means that reports should be written clearly, concisely, accurately and objectively. Using the GAS (Goals and objectives, Audience, and Structure and style) model will help you plan the report, record or other document before you begin to write (Bogg 2015).

Holistic Needs Assessment in the Homelessness Sector 

In the homelessness sector, national policies such as the National Quality Standards Framework for Homeless Services in Ireland (2019) provide that a support plan addresses the housing needs of the service user by achieving housing-related goals and considering personal preferences and tenure options. In addition, the holistic needs assessment records the service user’s key information, their housing history and needs, family and current relationships, early life and childhood experiences, education, work and job history, legal issues including offending behaviour, income and finance, general physical health, mental health, alcohol use, drug use, independent living skills, equality issues and the service user’s own assessment of need. The holistic needs assessment is an important tool that facilitates care planning for people experiencing homelessness that is person-centred and offers the potential to map pathways out of homelessness. The support plan must also detail preferred areas, level of support required and include a risk assessment. In addition, a social care worker in the homelessness sector must prepare daily reports which provide a brief overview of the resident’s day, such as appointments attended or a synopsis of key working or significant conversations.

When filling in the holistic assessment form, it is good practice to detail as much information as possible from previous records and to check the accuracy of the information with clients. It is important to become familiar with the information to encourage a fluid conversation. Many of the subject areas are inter-related, such as addiction and the impact on financial resources. Sometimes this can present inconsistent or contradictory information as everyone has different interpretations of life experiences. If this occurs, you may ask for clarification, but if the client is not comfortable talking about a particular aspect, you can move to the next question. The main aim of the holistic assessment is to identify and prioritise areas for action and the supports to enable them. The holistic assessment form may take up to an hour to complete with the client, so it is important to allow sufficient time and to find a quiet location where the confidentiality of the service user is protected and where they feel comfortable and at ease when sharing information with you.

Goals and Objectives

• The goal and objective of this report is to provide an objective and factual insight into Alice’s situation.
• The holistic needs assessment also sets out the strengths, needs and risks in Alice’s life.

Audience

• The report is person-centred and therefore Alice will be contributing and reading its contents.
• Your line manager may read the report.

Structure and Style

• The holistic needs assessment will be available in template form and you will need to provide a clear, concise, accurate and objective report based on the information provided to you by Alice.
• The main topics are outlined in the template.
• The assessment also provides an opportunity for Alice to identify her own assessment of needs.
• This report should be written in a formal style.

References 

Bogg, D. (2015) Report Writing for Social Workers (2nd edn). London: Open University Press.

Dublin Region Homeless Executive (2019) National Quality Standards Framework for Homeless Services in Ireland. Dublin.

Griffiths, C.R. (2010) Attuning: A Theory of Interaction with People with Severe and Profound Intellectual and Multiple Disability and their Carers. Dublin: Trinity College.

McDonald, D., Boddy, J., O’Callaghan, K. and Chester, P. (2015) ‘Ethical professional writing in social work and human services’, Ethics and Social Welfare 9(4): 1-16.

Stanton, N. (1990) Mastering Communication (Professional Master series). UK: Palgrave Macmillan.

Social Care Workers Registration Board (2017) Standards of proficiency for social care work. Dublin: CORU Health and Social Care Regulator.

Webber, M. (2015) Evidence-Based Policy and Practice in Mental Health Social Work. London: Sage Publications.