When we work in mental health settings, one of the ways we communicate is through paperwork. This might involve writing support notes, amending care plans or writing memos or minutes of meetings.
The purpose of a written report is to reflect an accurate account of the interaction and/or an up-to-date picture of an individual’s situation. Where possible, this should be done with the person involved. The report is also used to provide an historic record that can be referred to at some point in the future to remind the person.
It is very important to write about people in a respectful way. The information that is written in files or notes must be factual and free from opinion or prejudice. Remember that information in personal files should reflect a period in a person’s life. Often, the behaviour and reactions of the individual will not necessarily be wholly to do with who they are, but could be a response to the situation they have found themselves in, the environment they are in or how others interact with them.
For example, a person might show aggressive outbursts, and these will have been recorded as part of their mental health issues at the time. However, the aggressive outbursts might be a reaction to the environment they are in and how they have been treated or (or have perceived themselves to have been treated) at that time.
Always consider how the content of your writing might be interpreted. As stated previously, a peer supporter’s written account should be factual and free from bias and opinion. It’s preferable to co-write notes with the person concerned. For example, you might ask the individual you’re working with how they would describe a situation or an interaction, or you could write your notes jointly as a summary of the time you’ve spent together.
Written records containing elements of bias or opinion can be dangerous, as they can provide a mind-set for the individuals reading them. This can foster unreasonably negative thoughts, beliefs and opinions about the person being described.
For example, by writing, ‘Stacey is refusing to go to the appointment that we arranged at the Housing Office again’ the words ‘refusing’ and ‘again’ are loaded with innuendo that is consciously or unconsciously saying to other team members that Stacey is not engaging with the service and that this is a bit of a pattern. The danger here is that others work harder at ‘making’ Stacey engage and/or abuse their power to ‘force her into line’. If Stacey doesn’t want to go to the Housing Office, simply record that ‘Stacey decided not to attend her appointment at the Housing Office’.
Poorly written accounts can have a negative impact on our ability to assess situations independently and holistically, which can give rise to poorer support or inappropriate interventions for individuals.