If just reading the words "The Report" gave you a migraine headache and some unpleasant stomach cramps, then sounds like you are already familiar with the report writing process ;-)
If you had no reaction, then let me introduce a part of the job description for a supervisor/BCBA: Report Writing.
In most scenarios, when you begin working with a new client there is an assessment process that concludes with writing up a formal report. Depending on the funder, this report needs to be updated at specific intervals, such as every 6 months.
The purpose of the report is to summarize the treatment plan, and justify the need for services (or with a progress report, to continue to justify the need for services).
For newly certified clinicians the learning curve of report writing can be quite steep (I know it was for me). The report may need to include specific sections such as: Client Demographic Information, Client Diagnosis, Current Medication, Current & Former Therapies, School Schedule, Assessment Results (complete with grids/graphs), Functional Behavior Assessment, Coordination of Care, Transition Planning, etc.
Having strong written communication skills helps, as does being adept at Case Conceptualization, and compiling the report from strong assessment results. If the assessment process was rushed, skimpy, or otherwise flawed, then don't expect to write a stunning report from that data. The data collected during the assessment process are the foundation for the report to come. Don't neglect to gather important information during Intake/Assessment, as this will cause problems down the road.
But first, a quick disclaimer: The clinical report is not a one-size-fits-all document. Your employer and/or the funding source will have specific requirements for how reports must be written. It's also important to consider the target audience: who is going to read the report? Reports are often written in very technical language that may be difficult for laypersons to understand, which means that someone needs to interpret the report to laypersons and review each section in detail. When in doubt, follow the report guidelines communicated to you by your employer, or the funding source.
So let's jump in to some very generalized tips to clinical report writing:
- I already mentioned above, but before even starting the report the assessment data are KEY. Having organized, accurate information (including any graphs or data sheets) at your fingertips will save SO much time when sitting down to write the report. Random pieces of paper scattered all over your desk? Not so much.
- Follow the template provided to you. Your employer should have given you a report template to use (which can often vary from one funder to the next). Following the template saves time, and decreases the chances you will have to make tons of edits later. If your employer embedded drop down menus into their template? Gold star for them. If you work for yourself, make a template. It saves time.
- If possible (because this may not be your choice), use an electronic data management system for reports. An electronic system will store collected program data, and generate its own graphs, so when it comes time to update the initial report you will save SO much time by not having to enter all this information in yourself. Oh and by the way, the amount of time you can bill for report writing will be a drop in the bucket compared to how much time it takes you to write it. So saving time in this process will be suuuuuper important.
- Always, always, always, always --> read your completed report multiple times before submitting. Be on the lookout for spelling errors, referring to a graph and then forgetting to include the graph, weird formatting glitches, dropped words/missed words, correct client name, etc. Trust me when I say you don't want to hand off a completed report to a family, school, or supervisor, and have them notice a really simple error that you missed. It's embarrassing.
A well written report presents a full snapshot of the client, and thoroughly lays out a plan of action (including the clinical reasoning for choosing the plan of action). Selected goals are developmentally appropriate for current abilities, behaviors targeted for reduction are identified and described, and any barriers to instruction/progress are clearly stated with a specific plan for how to overcome these barriers during the period of authorization for services.
*Resources:
Best Practices in Client Documentation
BACB Practice Guidelines
Papatola, K. J., & Lustig, S. L. (2016). Navigating a Managed Care Peer Review: Guidance for Clinicians Using Applied Behavior Analysis in the Treatment of Children on the Autism Spectrum.
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