Writing Defensible Documents

understanding defensible documents and writing more robust case notes and reports

This one-day course explains why case notes and reports need to be robust and fully defensible. It illustrates how and where they could be used; for example: appeals, tribunals, litigation. It also provides hints, tips and guidance on how to write them in a way that will, better, withstand scrutiny and challenge.

The extent to which case notes and reports can be used to support any decision, defend during appeal, litigation or court action is highly dependent on the way they are written. In the event of any challenge to a planned or past course of action it is imperative that all the supporting case notes and reports detail facts accurately and robustly and in a way that will withstand rigorous interrogation.

Writing high quality case records and reports in a way that allows them to be defensible documentation also leads to a better level of care for service users. Robust tracking, recording and planning improves the consistency of care and allows for better identification of changes in the service user’s condition.

High quality records and reports also provides major benefits for staff. They provide vital reminder of key information and give staff the peace of mind that every aspect of care has been completed correctly. They also provide robust evidence to show that staff are fulfilling their duties properly.

For Whom
This workshop is suitable for those working in client service sectors, for example health, welfare and social care, who may at some time have to write case notes and reports that may be subjected to scrutiny third party organisations including quality bodies, funding agencies, lawyers and courts.

Aims and Objectives
To provide participants with a good understanding of how, why and when case notes and reports may be subject to rigorous scrutiny by third party organisations and to provide advice and guidance on how to write in a way that is more robust

CONTENT

  1. Writing High Quality Case Notes and Reports

This introductory session reminds participants of underpinning reasons for writing case notes and reports. In doing so it explains how, where and why the different documents are used. This session also highlights how differences of opinions can lead to challenge, appeal, litigation or court action;

  • The differences and similarities between case notes and reports
  • How where and when case notes and reports are used
  • The case for robust case notes and reports
  • Service users, staff, management, organisational perspectives
    • legal documents that provide clarity on rationale
    • record what worked, what didn’t and why
    • Gaining legal protection from liability by demonstrating planning and rationale
    • Demonstrating that the practitioner conducted themselves competently and professionally
    • Evidencing service user treatment and personal progress
    • Duty of care
  1. Defensible Documentation and Breaking News

In the event of challenge, appeal, litigation or court action there will be a need to reference back to the appropriate case notes and reports, this session illustrates the levels of interrogation the documents may be subject to and provides some examples of case studies and reports that were found robust and some that were not.

  1. Over Arching Principles – The dos and the don’ts

Section 3 explores the general overarching principles that apply to both case note and report writing

  • Organisation and sector specific structures must be followed
  • Organisational policies on record-keeping and confidentiality must be complied with
  • The role of personal opinion
  • The need to avoid emotional reactions/opinions/unfounded speculations/assumptions
  • The importance of Goals, clinical observations, assessment, evaluation of goal attainment & interventions used, plan for next session/future action, other relevant info e.g. test results
  • Write for a wide audience – yourself in the future, colleagues, client, auditors, a judge!
  • Be succinct clear and avoid professional jargon, slang or abbreviations
  • Understanding what to avoid:
  • Acronyms, clichés, vague terms and meaningless statements
  • negative speculations/assumptions, judgemental or stigmatising language
  • Frequently misunderstood words
  • Choosing words carefully’ – similar words can mean different things

4. Writing Case Notes

  • When to record
  • Ground what you write in what your client tells you
  • Typical Structure
    • Date Order
    • SOAP – Summary (from client), Objective Data, Assessment of Situation, Plan
    • FOSC – Factual, Objective, Specific, Clear and to the point
  • Good Practice Audit Reflection
    • Clients are aware of rights (informed consent)
    • Confidentiality is not absolute (safety overrides) and client has been informed
    • What information has been collected directly from clients and others
  • Include case note alerts if safety issues identified + rationale
  • Never be altered/changed retrospectively (line through words if ‘corrected’ and note reason)
  • Be kept ‘up-to-date’ – file closed if ‘fully discharged’
  • Connect actions and interventions to the purpose of client attendance at the service

5. Writing Reports

5.1 Being Succinct
The importance of writing succinctly and eliminating waffle

    • Sentence construction and paragraph length
    • Using short, punchy words and eliminating surplus words

5.2 Spelling and Grammar

  • The need for accuracy and proof reading
  • US/UK spellings, punctuation, capital letters, tenses

5.3 Structures, Styles, Suitability and Choice
This session explores a typical structure and considers when, where and why variations may occur.

  • Typical Structure
    • Executive Summary, Contents, Introduction, Aims and Objectives
    • Headings and Sub Headings, Conclusions and Recommendations
    • illustrations, Graphs, Tables, References, Appendices, Signposting
  • The importance of knowing the purpose and planning the structure before writing
  • Deciding on Style: factual, descriptive, explanatory, discursive, analytical, SWOT, PEST
  • Active or Passive Voice – what to use where
  • Checking arguments