Recovery focused note writing

The purpose of this document is to provide some guidance on how to write notes in a recovery focussed way while meeting the expected standards for clinical notes. It originates from discussions held during peer support development meetings where it was identified that some guidance on how to write in a recovery focussed way would be helpful, both for Peer Support Workers and staff members that they work with. With an appreciation that clinical systems do not always support radical changes, it is hoped that the document will provide some guidance for note writing within the existing clinical context.

The existing note writing policy provides guidance on the legal and practical requirements of writing notes. This is very helpful, however often the focus of guidance becomes about documenting and managing risk with the possible use of the notes in a coroner’s court. While safety is clearly an important priority in clinical notes, this can be included alongside other, recovery focussed priorities such as seeing strengths and valuing the whole person. It is important to understand that a recovery focussed note does not ignore negatives or understate a person’s difficulties. This would not be a helpful alternative to current practice. Below are some general guidelines which are intended to offer support in writing recovery focussed notes.

• Gives a full reflection of a person- for example, instead of focussing on specific domains such as medication or housing, includes more personal details about what is important to them
• Uses carefully considered language and reframes negative interpretations. For example, in place of the term ‘demanding,’ a person’s actions could be framed in terms of their assertiveness or their expectations of the service.
• Written with the person in mind – holding in mind the person who the note is about will ensure it is respectful and balanced
• Where possible Co-authored with the person

There is no template that can be used to write a recovery focussed note as notes vary hugely depending on the nature, length and depth of a meeting as well as the service context in which it took place. Below are some suggestions of what to consider when writing notes.

 

Focus on:

• Relationship building – relationship between staff and person is often not included in notes
• Include information that will help people reading the notes to build a relationship with the person so that they do not have to repeat themselves
• The self-discovery of a person based on their strengths
• Including the person’s perspective and allowing this to have importance alongside the perspectives of staff
• Barriers
• Factual information, descriptions
• End with intentions for future in line with a person’s wishes and goals
• Length
• Simple, unambiguous, non-jargon language

 

Try to avoid

• System focus - Writing notes in situations where you have not interacted with a person to meet the demands of the system. Try to check in with a person and have some dialogue or ask somebody else who has done this to write the note
• Disease focus – unnecessarily focussing on symptoms, instead of experiences. Interpreting people’s actions in terms of their diagnosis, rather than taking into account their wider situation
• Slipping into team language which does not celebrate or respect the person, for example ‘no management problem’
• Judgemental terms- some language can unintentionally place blame on a person, for example ‘non-compliant’ or ‘did not engage’ suggest the fault lies with the person whereas it may be more balanced to say ‘disagreed with medication’ or ‘did not feel like talking to me on this subject’

To begin to reflect on personal note writing styles and consider alternatives may potentially make the process of writing notes take longer initially. As this becomes more natural, the time it takes to write notes is likely to return to normal. In addition, the process may feel uneasy initially if it conflicts with the norms of the surrounding staff team. Changing practice is requires courage and support.

The below is an example of how a health professional might write their notes, followed by an example of strengths-based notes that are informed by recovery-values:

 

Health professional example 

John refuses to leave the flat because of adjustment disorder and social anxiety. Agreed to meet him at his home. Appears to be ritualistic and territorial with first rank symptoms of psychosis. Wants to use CBT principles to address these fixed beliefs. Informed him of current waiting times. History of non-compliance with medication. Haloperidol to be augmented with Aripriprazole. GP to prescribe and dispense medication. Speak with Dr for plan. Plan to see John in 2 weeks to commence assessment process.

 

Stregths-based example 

John requested that we meet at his house as this is where he feels most comfortable. John said that he has been struggling with some of his behaviour patterns since we last met. He said that he has certain systems of behaviour which he uses to cope but that he would like to work on changing these as they are becoming difficult to manage. I commended John on his motivation to change. John asked if CBT might be an option which would help him with this. I said that this was a well selected option, and that if he would like I would refer him to a CBT practitioner. I told John that there might be a waiting list for CBT and offered my support while he is waiting to be allocated a CBT specialist.

John said that he is more willing to try psychological approaches than medication, which he struggles to take. We discussed the benefits and challenges of medication and I offered to arrange a review with his psychiatrist to discuss reducing his current dose of Haloperidol. John said that he would like this.

John sometimes appeared distracted during my visit and my instinct is that he is hearing some voices; I will ask John about this during our next visit. After 15 minutes, John asked for me to leave as he was uncomfortable with having people in his house for too long. We arranged to meet again next week.

Action: to refer John to CBT services at his request. To continue to meet with John and support him to change his patterns of behaviour at a pace which he chooses. To arrange a review with John’s psychiatrist, to take place in John’s home.