You may have been an amazingly creative writer in school but now the skills that made you so talented then, are giving you difficulties when you are being asked to write a professional report. Professional report writing in some sense is the opposite of creative writing. As a speech and language pathologist, you will be asked to write many reports and record notes on your clients. It is important to know some simple rules to assist you in becoming more proficient in professional writing.
- Report your findings objectively: only report what you have data on without qualifiers that are not measurable.
- If there are any discrepancies in your testing explain these but again be careful that you don’t attribute it to something that you can’t measure. ( INCORRECT: Rob was bored so he did not answer any of the comprehension questions correctly.)
- Always be respectful in your language. If you have a difference in opinion about another therapist’s approach or the follow through on home programming the progress report is NOT the place to voice this. ( INCORRECT: The family never turned in the homework, CORRECT Home programming was best accomplished through discussion with the family about therapy goals and how they might incorporate them into their daily life)
- DON”T COPY from a previous report. Many things might have changed from the last progress or evaluation report. As someone who reads and corrects many reports there are times that I have seen the wrong spelling of name, diagnosis or goals from school carried over from one report to the next. This is a dangerous practice. It is also important NOT to use another child’s report as your template for a different child. Nothing is more upsetting to a family than to read the incorrect name in a report. They either will feel that they have the wrong report or that you did not take the time to consider the unique needs of their child.
- Only report and comment on what is in our scope of practice. You may feel that the child who is running around the therapy room may have attention deficit disorder but you are NOT qualified to say this. You may report what you observe but DON”T diagnosis.
- In writing your prognosis statement write your rationale. It is better in this section not to be too specific but rather to discuss this broadly ( INCORRECT: In two years he should be dismissed from therapy. CORRECT: Given family support, student’s efforts and progress made this semester Chris’s prognosis is considered favorable for continued growth.)
- Use professional language but also explain those terms that might not be understood by non-professionals.
- It is better to spell things out and not use abbreviations. Too many abbreviations make it appears as if it is alphabet soup! You may write out the name of a test and then in parenthesis write the abbreviation the first time and then after use just the abbreviation.
- The same way that abbreviations can be confusing so can contractions. Please write full words out ( INCORRECT They’re CORRECT They are).
- If there is something that you are interpreting then you need to make this known to the reader. ( CORRECT: It appeared as if he did better when visuals were included with the read aloud. The data demonstrated that the use of tactile cues netted higher percentages of correct responses).
- Avoid using conversational speech in your reports or notes. ( INCORRECT Maggie really got a kick out of the game. CORRECT Maggie requested that the game is played again.)
- Write in the third person! ( INCORRECT: I administered the Entire World of R CORRECT: The Entire World of R was administered.)
- Write information in behavioral terms ( INCORRECT: Bob is able to follow two-step directions CORRECT: Bob followed two-step directions).
- Make sure that you clearly differentiate between your observation and data and information that has been provided to you ( ex. If the family reports that a child is saying a sound at home report that in this way rather than just saying the child is carryover sounds).
- List all data or test scores before you interpret them. It is best to put test scores in a table as it is easier to read numbers in this way.
- Remember to state the student’s strengths as well as their weaknesses. No one wants to only hear what they can’t do. But be careful with strengths that you also are only stating what you are measuring ( INCORRECT He is a very smart boy. CORRECT: He is able to quickly solve puzzles).
- Remember that the summary statement is a statement of what you have reviewed before. Do not bring up new topics that have not been addressed in the body of the report.
- Read your report out loud or use a screen reader. You can catch many grammatical errors or sentences that are poorly organized that way.
Paperwork is part of the job but following the above guidelines and practicing will make it easier.