Writing Defensible Documentation

understanding defensible documentation –
writing defensible documents, case notes & reports

This one-day course explains defensible documentation and explains how to write defensible documents, defensible case notes and defensible reports. It illustrates how case notes and reports are often scrutinised during appeals, tribunals, litigation. The course is full of highly practical hints, tips and guidance on how defensible writing and how to write defensible documents in in a way that will withstand robust 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. It includes training on writing SOAP notes, SOAP documents and SOAP writing.

The course helps improve the quality of documents, case notes and reports. It is considered essential for all staff working in the health, care and related sectors

Writing high quality records and reports from a defensible disposition also provide major benefits for staff. They provide a 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.

The approaches that make for effective defensible documentation also deliver benefits in terms of patient care and service. The more robust tracking, recording and planning that falls out of wiring high quality defensible documents improves the consistency of care and allows for better identification of changes in the service user’s condition.

For Whom
This course is suitable for those working in the client service sectors, for example health, welfare and social care. It is especially appropriate to those who have to write case notes and reports.

Aims and Objectives
To give participants 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. Setting the Modern Scene – External and Internal Focus
    This introductory session looks at key definitions, considerations about “getting it right first time” and things that can go wrong. Participants are encouraged to flag up any issues or problems they have encountered in drafting documentation with either remedial action being suggested and/or parked as an organisational issue to be addressed after the course. Key content of this session includes:
  • Definitions – Defensible Documentation?
  • Case Notes and Reports – Differences and Similarities
  • The case for getting things right – benefits
  • What happens when things go wrong?
  • Indicative expectations from statutory bodies such as the Care Quality Commission
  • Internal expectations, policies and procedures
  • Breaking News
  • Samples of poorly drafted documents – Q & A’s
  1. An A to Z Defensible Documentation Framework for Quality Case Notes and Reports

This in-depth session explores a robust, 21 component, A-Z framework of advice, guidance and direction for drafting and writing high quality documentation. It includes critical reminders of and references to the key learning points from the preceding session.

Threaded into the 21 components are considerations around accountabilities, authorisations, chronology, communication, consent, confidentiality, evaluations, expert clinical or other input, external liaisons, fluency, internal policies, goals, legibility, objectivity, ownerships, planning, personal bias, recommendations, sensitive data, subjectivity and timelines; together with the caveat that on occasion some of the components may not be needed and/or fresh considerations may need to be addressed.

All enabling clear action plans to be taken forward and creating an accurate historical record for future reference in should it be needed in the short, medium or longer term. Key content for session 2 includes:

  • Typical Structure – Including possible variations in templates from session 1
  • SOAP – Summary (from client), Objective Data, Assessment of Situation, Plan
  • SOAP Notes and SOAP Writing
  • FOSC – Factual, Objective, Specific, Clear and to the point
  • SMART & SMARTEEER
  • The Defensible Documentation A to Z Framework – 21 key points
  • References and signposts to appropriate Internal policies as well as protocols for “signing off” at a senior level when appropriate
  1. Going Live – Applying the A to Z Defensible Documentation Framework to Real Cases
    An A to Z framework is only as good as its application in the real world with real cases.

Session 3 provides participants with the opportunity to “go live” and consider the impact of documentation based on real cases drawn from the Care Quality Commissions and the Government’s Safeguarding websites. Participants are encouraged to identify which parts of the defensible documentation A-Z framework are applicable, why there is applicability and how/where using the framework could have strengthen the case.

Studies covered include:

  • Death in Service
  • Dysfunctional Family
  • Person with addiction issues
  • Person recently released from prison
  • Single Parent
  1. Tools for the Job – Plain English Toolkit – The dos and the don’ts
    Session 4 emphasises focusses on the need for plain English. That is to say writing and language that is clear and concise. Plain English avoids complex vocabulary. It attempts to be free of clichés and needless technical jargon and should be appropriate to the situation being documented. Some humorous and lively examples from the world of advertising and marketing illustrate the importance and help embed the learning.

A comprehensive post course reference document is provided

Soft skills such as active listening, questioning techniques and observation are considered as further aids to good writing, together with good practice protocols on checking written content with managers and appropriate colleagues.

  1. Closing – Evaluations and Signposting
    This final session will bring the whole course together and signpost the next steps.
  • Final Q and A’s
  • Parking Bay Issues – addressed here or forwarded for internal review
  • Evaluations