Writing reports and keeping records is absolutely critical to client care. Without an accurate history of a client’s progress, collaboration between caregivers becomes impossible, goal-setting becomes pointless, and prescribing medicine or therapies becomes dangerous. You’ll need to demonstrate the ability to keep records that are accurate, reflective of ongoing care and prognosis, and that contain enough information to allow other caregivers to make treatment decisions. In this blog, we’ll look at ways to keep records that support specific benefits for the client.
Goals
The saying, “You don’t know where you’re going until you know where you’ve been” is particularly appropriate here. In order to set reasonable and attainable goals, your client will need to know what their rate of progress has been and what they can expect it to be. Records on previous goals, methods used to reach them, and whether they were successfully met will provide insight into what strategies will best suit the client. You’ll also need to demonstrate that you can review previous records kept by other counselors and use the information in them to determine the best course of care.
Communication
One of the main functions of a client’s history is to facilitate cooperation between counselors within an agency and between agencies and one another or community resources. In order to do this, you’ll need to use correct terminology so misinterpretations can be avoided. Facilitating with appropriate and specific language will be required. In addition to precise medical definitions, you’ll need to be able to write reports in behavioral terms as well.
Oversight
From management at the agency to the organizations and departments that fund the agency, every step of client care requires oversight. In order to make your record keeping most useful in this regard, be sure to keep all of your reports totally objective. Personal bias or feelings about the client should not make their way into any writing. As part of the expectation of clear communication, you will be required to demonstrate objectivity.
Continuity
With properly reported documentation, a client should be able to go to a doctor who’s never seen them before and obtain care that is continuous with the care you’ve provided up to this point. During the course of overseeing ongoing care for your client, it’s likely that you’ll work with specialists or community resources to expand the range of care your client is receiving. You should be able to clearly and accurately present a full case history in order to support this function.
To make records more useful in all of these regards, you’ll need to be able to write reports that are concise, comprehensible, and articulate. You’ll need to be able to describe a client’s experience and your experience treating them in a way that any other care provider could understand. In order to demonstrate that you’re able to perform this core function, you’ll need to utilize strong writing skills, attention to detail, and an ability to organize information well.