Write reports and letters

The seven: Clinical Assessment Report, Comprehensive Clinical Summary, Legal Support Letter, Immigration Clinical Assessment, Treatment Attendance and Progress Letter, Disability / Accommodation Letter, and Medical Necessity Letter.

1. 1

   Step 1: Open the client, then Reports > Generate report… (or Clients > Letters and reports > Write draft).

2. 2

   Step 2: On the checklist, say who it is for and why, tick the sessions to use, say whether third parties are relevant, and fill the gaps only you can. Only a ticked session is required.

3. 3

   Step 3: Press to write it. It takes a few minutes and shows in the footer.

4. 4

   Step 4: Before it is saved, a screen lists wording the notes do not use and sources that disagree, for you to keep or remove. Saving is never blocked.

5. 5

   Step 5: Open it from Saved reports to edit, Sign…, Copy or Export as Word or PDF, including a password-protected PDF.

• Every report ends with recommendations, a limitations statement and your signature block from your Profile.
• Diagnostic impressions are left out unless you choose them (Settings > Profile, or for one report). Include them only if your licence or role permits it.
• Never in a report: fees, insurance, appointment times, or words and referrals the notes do not contain. Third parties are named by role.