Document clinical assessments, interventions provided and outcomes accurately and coherently

Organise reports that allow for thoroughness and accuracy of records, and efficient retrieval

Comply with the construct, ethical and legal standards in report writing and documentation

Prepare documents for review by supervisors in compliance with the organisation’s review guidelines

Maintain privacy, confidentially, security and integrity of all client records

Maintain and store client records in accordance with clinical, organisational and professional criteria

Explain reasons for evaluation, context for referral, and client background information

Demonstrate attentiveness to situational factors that impact client's psychological status

Complete reports that are coherent and accurately reflect assessment procedures, assessment and synthesis of findings based on evidence- based practices

Review reports to ensure compliance with all requirements to be defensible in court

Convey in reports the limitations of psychological assessments and conceptualisations

Describe instances of lack of progress and actions taken in response to psychological treatment

Balance client care, preferences and requirements with legal and ethical requirements, risks and emergencies in reports

Recognise impact of wider access on confidentiality to client records within multidisciplinary settings, ensuring information recorded is congruent with organisational requirements

Determine need for separate storage of sensitive information within multidisciplinary settings

Implement processes that support the protection, transmission, storage, access, disclosure and disposition of confidential information and in accordance to proper consent, court orders or other required circumstances

Preserve contexts of records to protect the client from the misuse or misinterpretation of data

Educate or coach psychologists on confidentiality, legal and regulatory requirements and ethical standards in report writing and management

Supervise psychologists in report documentation and review reports prepared to ensure completeness, accuracy and compliance to organisation’s standards of report writing

Implement and ensure compliance to best practices in report writing and management

Develop and drive implementation processes that support the protection, transmission, storage, access, disclosure and disposition of confidential information

Drive the establishment of security procedures regarding use of computers or other electronic storage devices to protect confidential client information

Develop disposition plan in which provisions are made for the control and management of the records at time of unexpected events

Review best practices in standards of report writing and record keeping for adoption into organisational practice

Drive establishment of procedures which safeguard the misuse or misinterpretation of reports