69 RECORD KEEPING Actions Record Keep on file Referral/first contact * Set up personal health record * Client identification details * Reason for and date of referral or attendance * Name and position of the referrer * Referral form or letter/admission slip * Accompanying reports Initial * Evaluate clinical need * A case history * Case history form or admission sheet assessment * Client’s views about the problem * Clinical observations * Tests, investigations and procedures * Interpretation * Diagnosis/prognosis * Actions/recommendations * Consent forms for specific investigations * Forms or charts used in tests, investigations or procedures * Communication about assessment * Client’s concerns and views on the assessment and outcome * A copy of reports or letters circulated about the assessment * Refer on as appropriate * Copies of referral letters to other professionals Intervention * Set careplan * Record objectives * Consent forms for treatment, therapy * Record client’s views about careplan or surgery * Careplan Figure 4.1: Summary of record keeping at key stages in the care process 70 WRITING SKILLS IN PRACTICE Actions Record Keep on file * Implement careplan * Evaluate careplan * Record interventions * Record client’s responses * Record outcomes * Record clinical decision making * Progress records Discharge * Re-evaluation of clinical need * Preparation for discharge * Discharge * Communication of closure intentions * Results of investigations, tests or procedures * Treatment outcomes * Assessment of the client’s ability to manage on-going care needs * Liaison with other agencies * Views of the client and client’s family or significant others * Advice/instructions to client and family/carers * Date and reason for the discharge * Name and status of the clinician who made the decision * Discussion with client/referrer/other professionals about closure intentions * Results of assessments relating to discharge decision * Copies of referrals to other services * Copy of discharge instruction sheets * Discharge report Post-discharge * Retention of records for recommended minimum period of time * Complete administration procedures relating to storage and future retrieval of records * File record in secure storage Figure 4.1 cont’d 5 Letters and Reports Letters and reports about the care and management of clients are an essen - tial form of communication within the health service. This chapter reviews how to plan, structure and present such correspondence. Letters There are two types of letter – formal and informal. The two are distin- guished from each other by different styles, presentation and tone. Formal letters refer to correspondence that has an official or business function. They are printed or typed on headed paper using a conventional style of composition. The manner of address is formal rather than personal, so the preferred title and last name of the recipient is used to start the letter. They are signed off with the name, position, title and qualifications of the letter writer. Informal letters are written using a more conversational tone and are sent between two people who know each other. The usual form of address in these letters is by the first name. Letters are only one of the means of communication available to the health professional; however, they have certain advantages over other methods. Choose a letter if you want to: ° present complex information and elaborate on ideas ° have time to organise your thoughts and review your intended message ° have a confidential means to convey information 71 72 WRITING SKILLS IN PRACTICE ° indicate to the recipient the seriousness of the matter under discussion. Sometimes a letter is not always the most appropriate or most sensitive choice of communication. If your message: Consider using: is urgent e-mail, fax, telephone is an apology telephone, face-to-face contact requires explanation face-to-face contact, telephone is informal, brief or a reminder e-mail, memo requires discussion or exchange meeting, of ideas or involves decision making video or telephone conferencing. Structure of letters Letters consist of: ° a greeting ° an introduction ° the main body ° the conclusion ° a closing sentence ° a signature. Greetings The way in which you address the recipient will depend on whether you are writing a formal or informal letter. In certain circumstances a more gen - eral term like ‘client’ or ‘parent’ may be permissible in letters sent en masse or if you are unable to verify the recipient’s name. Introduction The first paragraph will state clearly the reason or purpose for writing. 73 LETTERS AND REPORTS The following examples show how the use of some pertinent details (including the date) helps the writer indicate the topic or subject of the message to the reader. In response to a letter or other type of contact – ‘Thank you for your letter dated … regarding …’ or ‘Thank you for your phone call on the … I am sorry I was not available to speak to you personally’; ‘I am writing to you regarding your enquiry on the … about the waiting list for day sur - gery.’ To make an enquiry – ‘I am writing to you regarding the shortage of car parking at Ginsbury Health Centre. I would like to find out whether it would be possible to install a barrier that will restrict access to staff mem - bers.’ Some letters start using a traditional format. For example, referral let - ters usually start with a sentence like: ‘Thank you for seeing this elderly gen - tleman who has been complaining of chest pains for the last three days.’ The main body This contains the main message of the letter along with any supporting de- tails or information. Conclusion The content of the conclusion will vary according to the purpose of the letter. It may include a summary, recommendations, request for action or a statement of what is expected from the recipient. Closing sentence A letter is usually brought to an end by the use of a closing sentence. For example, ‘I look forward to hearing from you’, ‘Please do not hesitate to contact me if you need further information’ or ‘Thank you for your assis - tance in this matter.’ The addition of phrases such as ‘best wishes’ or ‘kind regards’ helps to add a courteous note, particularly in informal letters. Signature Letters must always be signed, as they may be required as evidence in the event of a complaint or litigation. The signature shows that the health pro - fessional, or another person authorised to do so in his or her absence, has checked the letter and agreed the content. Formal letters require the signa - 74 WRITING SKILLS IN PRACTICE ture to be accompanied by the title, position and in some cases the qualifi - cations of the letter writer. The subscription accompanying the signature will depend on the form of address used in the greeting. A letter starting with ‘Dear Sir/Madam’ will end with ‘Yours faithfully’, whereas one starting with the first name, or title and last name, will end with ‘Yours sincerely’. Layout and format of a letter Letters are set out according to a standard format. Figure 5.1 is an example of a standard layout. Remember: ° Keep text well spaced with the left-hand margin aligned with the start of the recipient’s address. ° The current style is to have ‘open punctuation’ (Dobson 1995), where punctuation is kept to a minimum, so avoid using full stops and commas in headings, addresses and dates unless the clarity or meaning is affected by leaving them out. ° Any special messages, like marking the letter ‘confidential’ or for the attention of a specific person, also need to be marked on the outside of the envelope. ° It is not necessary to repeat headings on any continuation sheets; however, they should be numbered. Mark the bottom of the preceding page with ‘cont.’. ° Use ‘date as postmark’ for large numbers of letters sent out at routine intervals. ° Include identification information on any tear-off slips. Include the name and address of where to return the slip, what it refers to (for example ‘diabetes clinic’) and any client identification information. 75 LETTERS AND REPORTS Heading (usually the logo of the organisation) Address (if not included in heading) (check position for window envelopes) Name and address of recipient (write on separate lines) (note this starts lower down the page than sender’s address) Date dictated: Date typed: Our ref: (initials of sender/typist/file number) Your ref: (any reference provided in previous correspondence from addressee) (align left-hand margin with start of address) Figure 5.1 Standard format of a letter 76 WRITING SKILLS IN PRACTICE Dear… Heading (subject matter or name, DOB, address of client) Introduction Main body Conclusion Closing phrase Yours sincerely/faithfully, (note the use of a small ‘s’ and ‘f ’) Space for signature Name in full (plus preferred form of address/ Position title, qualifications) (shows the recipient who else has seen the letter/informs the secretary of the circulation list) Cc (names of people who will receive a copy) Enc. (detail any enclosures, e.g. maps, timetable) Figure 5.1 cont’d 77 LETTERS AND REPORTS Writing a letter You may be about to write your first clinical letter, either during your clini - cal practice or as part of an assignment for college. The following section offers some guidance on the four stages in composing such a letter. They are: 1. Preparation 2. Planning 3. Drafting 4. Editing. 1. Preparation (a) Decide on your terms of reference What is your reason for writing the letter? Who is the most appropriate person to receive the letter? What is your timeframe? Who needs a copy of the letter? An additional question to consider is whether you are the most appro- priate person to write the letter. This is essential where situations are liti- gious. In these cases you may need to refer to a senior colleague or manager before proceeding. (b) Gather your facts Before starting the letter you need to make sure that you have all the rele - vant facts and figures. It is important to be accurate and to verify any infor - mation. Mistakes in a letter between clinicians may lead to misunderstandings or delays in the assessment and treatment of a client. Remember that your letter, like any other part of a health record, may be used as evidence in a court of law. Any mistakes are likely to reduce your credibility as a competent witness or defendant. 2. Planning You can start to plan your letter once you have established your terms of reference and gathered the necessary information. You will need to select information that is relevant for both the purpose of the letter and the needs of the reader. 78 WRITING SKILLS IN PRACTICE What is the purpose of your letter? Think about why you are writing the letter. Is it: ° to request information (for example information about previous treatment) ° to give information (for example test results) ° to request action (for example making a referral) ° to confirm an action has taken place (for example a discharge summary) ° to organise (for example making an appointment) ° to respond (for example replying to a complaint) ° to explain requirements (for example explaining procedures for making referrals)? Always consider your reader during the planning stage: What does he or she know already? ° This will help you to avoid any redundancy in your message. What does he or she need to know from your letter? ° This will help you in selecting relevant information and making your message specific. What are the reader’s expectations of the letter? ° You will have your own ideas about what you want to achieve. For example, you may judge your explanation of events a successful response to a client’s complaint. However, it may disappoint the client if his or her expectation was that the letter would also include an outline of intended actions to prevent future occurrences. Finally, decide on the logical sequence for presenting the information. Ar - range the data in the appropriate order using bullet points. This will form the basic plan for your letter. 3. Drafting your letter Write your letter for your reader: ° Choose your words with care. Avoid unnecessary technical terms or abbreviations, especially when writing to clients. [...]... within the health service ° They are a means of conveying information, making requests, influencing decision making and confirming actions ° Letters and reports are set out according to a standard format and often have prescribed terms of reference 92 WRITING SKILLS IN PRACTICE ° There are four stages in writing such documents – preparation, planning, drafting and editing ° Good writing skills involve... and the needs of its intended readers This will help in selecting the most relevant information and will determine the style and approach of the document 86 WRITING SKILLS IN PRACTICE What is the purpose of your report? Think about why you are writing the report The most common reasons for writing a report are: ° to inform (presenting facts and figures) ° to influence (providing evidence that will... clinic that the client will be attending ° Day, date and time of appointment ° Any instructions about preparation for the appointment (For example, bringing a parent-held record to a baby clinic, completing a registration form, or bringing a urine sample.) ° Directions about the location of the clinic and procedures, for example, ‘Book in with reception on level 2, North Wing’ ° Instructions regarding... into cohesive groupings List key points under the relevant headings from your report Asking yourself questions is a useful way of focusing your thinking, for example, ‘How do I know this child is showing a delay in gross motor skills? ’ This will help you select information that will help the reader to come to the same conclusion – for example, that the child has delayed mo­ tor skills 88 WRITING SKILLS. .. to indicate the point in time to which the information relates, for example, in his previous assess­ ment on …’ 84 WRITING SKILLS IN PRACTICE Conclusion This is a brief paragraph that summarises the main points of the report The conclusion to a report is often the hardest to write It is not the place to regurgitate lines from the main body of the text, nor should it contain any new pieces of information... to advise (offering recommendations) ° to explain (presenting interpretations) ° to record (documenting a contact) ° to summarise (providing a synopsis of the main points) What information does the reader require? The first step in preparing a report, just like any other piece of writing, is to consider the reader What is his or her existing knowledge and experi­ ence? This will determine how much detail... group discussion is audiotaped and analysed later 96 WRITING SKILLS IN PRACTICE Consult within your organisation Ask the information officer in your organisation about the types of re­ quests for information he or she receives from the public Clinical audits might also yield some information about complaints or plaudits regarding the giving of information Consult with co-agencies Talk with associated... might not be the way in which the client experiences his or her illness You need to start with what is most important to the client 98 WRITING SKILLS IN PRACTICE Be consistent Choose one term and use this consistently throughout the leaflet, for ex­ ample selecting ‘bowel’ to refer to the intestines and not interchanging it with other synonyms like intestines, colon or gut Explain terminology It may be... guidance on the four stages in constructing such a report They are: 1 Preparation 2 Planning 3 Drafting 4 Editing 1 Preparation Terms of reference You may find that the timing, structure and scope of your report are to a certain extent dictated by organisational guidelines In some circumstances there may be external factors influencing how you construct your report For instance, an expert witness report... unsatisfactory interviews Letter in reply to a complaint – key content ° Name, address and identification details of complainant ° Reason why you are writing the response (for example service manager, head of department) ° Apology (even just to say ‘I am sorry to hear that you have found our service unsatisfactory’) 82 WRITING SKILLS IN PRACTICE ° Results of any investigations into the complaint ° Clear . unsatisfactory’). 82 WRITING SKILLS IN PRACTICE ° Results of any investigations into the complaint. ° Clear statements about whether the complaint is refuted or accepted, supported by the following: °. It is therefore important to indicate the point in time to which the information relates, for example, in his previous assess - ment on …’. 84 WRITING SKILLS IN PRACTICE Conclusion This is. will help in selecting the most relevant information and will determine the style and approach of the document. 86 WRITING SKILLS IN PRACTICE What is the purpose of your report? Think about