Ch.16 Behavior Observation, Recording, and Report WritingCh.16 Behavior Observation, Recording, and Report Writing web_admin Mon, 12/27/2021 - 11:47
Author: Anne M. Nelsen, MSW, MPA
The old adage, “If it isn’t documented, it didn’t happen,” does not represent the truth. We do not write down everything that happens in our lives, day-to-day, hour-by-hour. A great deal happens to us that we do not document. However, in juvenile detention centers, juvenile correctional facilities, and adult facilities that serve youth, that old saying is not just a figure of speech, it is a truism. Comprehensive recording and report writing, based on vigilant observation of behavior and events, is essential to verify that something did occur and to record the details of the event.
There are two necessary skills for any line staff worker in a juvenile detention center, a juvenile correctional facility or an adult facility serving youth—the ability to observe behavior and events accurately and the ability to record them in a clear and concise fashion. Newly hired staff may or may not have these skills at an adequate level. They must receive relevant training to develop the desired capacity. Furthermore, there is no guarantee that the direct care worker will somehow learn sufficient skills in these areas by himself or herself.
It is essential for every direct care worker to observe effectively and to record these observations with accuracy. This also applies to shift supervisors, cooks, night shift workers, program counselors and other facility staff, and volunteers and contractors. This chapter will do the following:
- Define the purposes of behavior observation, recording, and report writing.
- Outline the skills necessary for observation, recording and report writing.
Observation is an active and continuous process. Observation is a teachable and learnable skill that improves with practice.
Facility staff are responsible for supervising the youth under their care. Supervision implies observation; observation is fundamental to supervision.
The answer to the question of “Why observe?” youth in facilities may seem simple, but it is actually complex and multi-faceted. In addressing that complexity, the following sections highlight some important reasons for observation.
Prediction. One role of juvenile detention centers, juvenile correctional facilities, and adult facilities that house youth is to evaluate and predict a youth’s behavior, to design an effective plan that addresses placement, treatment, and supervision needs. Detention, the court, and probation or social services agencies need information as they consider strategies that will balance the youth’s needs with those of the community. In juvenile and adult correctional facilities, staff must use observation to help establish treatment and service goals and to determine progress towards meeting those goals, including readiness for return to the community.
Conclusions. The juvenile court, placement agencies, treatment professionals, release or parole, and other stakeholders involved with the social, educational, and emotional development of troubled youth all need credible information about those youth. Juvenile or adult confinement can be an opportunity to collect information that helps reach conclusions about certain problems facing youth. Again, the quality of these conclusions rests on the quality of the observations that support them.
Behavior Change. Even though juvenile detention is not a treatment intervention, detention staff are frequently asked to work with youth to bring about specific kinds of change in their behavior. Those changes may help determine a youth’s readiness for return to the community. Furthermore, many juvenile detention centers have counselors or caseworkers that are responsible for a youth’s safe adjustment to long-term secure confinement, including potential placement in a juvenile correctional facility or even an adult facility. In juvenile and adult correctional facilities, youth have individualized treatment and service plans that entail goals and objectives that help to determine a youth’s readiness for release. Regardless of the confinement setting, good observation provides evidence that change has or has not occurred, whether that change involves achieving treatment goals or simply heightening a youth’s recognition of problematic behavior and ability to correct it.
Address Acute Issues. Youth in custody possess a range of risk factors that may lead to obvious problems and acute needs that must be addressed by the facility. Intake, custody, or healthcare staff must identify problems such as asthma, tuberculosis, STDs, a dental emergency, or other medical needs as well as concerns about hygiene, educational deficits (illiteracy) and emotional problems (PTSD). Detention staff should communicate their observations to appropriate clinicians, administrators, and other specialists to ensure that critical concerns are addressed as quickly as possible.
Effectiveness. As an extension of the change process, observation is used to evaluate the effectiveness of certain intervention strategies. Accurate observation becomes the evidence of behavior change and provides information to assist staff as they develop new intervention strategies.
Communication. When experts discuss the characteristics of competent juvenile facility staff, effective communication and staff consistency are always a part of that discussion. Good observation improves the quality of communication among staff members and between staff and residents. Greater accuracy and detail in staff communications leads to improved consistency in staff and resident interactions.
Intervention Timing. Behavior management experts stress the importance of accurately timing an intervention strategy to produce the maximum behavior change. Observation provides the needed information to improve the timing of interventions with troubled youth. Through good observation, patterns of behavior emerge that indicate when an intervention can be most effective.
Relationship Building. The more one knows about young people, the easier it is to express an interest in them, to talk with them, and to share concerns. Good observation—in conjunction with an effective system for communication—helps to facilitate interpersonal interactions and to build relationships.
Self-Control. Attentive observation leads to greater precision in supervision, which leads to increased consistency. Sloppy observation encourages youth to engage in behavior that they would not ordinarily engage in under close supervision; good observation encourages youth to behave appropriately, especially when the observation of appropriate behavior is acknowledged and effectively reinforced.
Staff Control. With an effective system of observation, residents are less likely to act out or misbehave. Consequently, staff members are less likely to use repressive control measures such as warnings, threats, or restrictions to maintain minimally acceptable levels of behavior.
Once constructive staff control becomes a standard tool for maintaining acceptable levels of appropriate behavior, staff may begin to focus on reinforcing these behaviors. Positive reinforcement is the most powerful strategy for creating and maintaining a safe and secure facility environment. The difficulty for juvenile and adult detention and corrections staff is that they are often more adept at recognizing and identifying inappropriate behavior rather than positive behavior. (See Ch. 14: Behavior Management)
To remedy this deficit, one institution asks new staff members to focus their attention entirely on positive behavior. Operating under a token economy, in which youth may be rewarded with tokens or points that may be exchanged for incentive prizes, new staff are directed to identify and reinforce 50 appropriate behaviors during an 8-hour shift. In nearly every instance, staff members remark that this was an enlightening exercise. Not only does it change their belief that they are supposed to catch youth misbehaving, it provides practice and enhances confidence in identifying and reinforcing appropriate behavior. If given the choice of responding to either appropriate or inappropriate behavior, most people prefer to deal with appropriate behavior.
Encourage Involvement. Programs that have a high expectation of close observation create the understanding, for both staff and residents, that being involved and attentive is the norm. Therefore, staff members understand that they should interact with youth. Engaged youth are less likely to assume that the best way to survive the institution is by doing nothing. They will participate in planned programs and activities and cooperate with the facility’s objectives of enhancing safety and youth interpersonal skills. Good observation works to reduce the tendency toward institutional passivity on the part of both youth and staff. Such passivity on the part of staff in a confinement facility can show indifference toward the job and the needs of the young people they are responsible for. Passivity on the part of youth may reflect apathy toward improving their attitudes and behavior.
Systematic Interactions. Good observation promotes better interaction between staff and residents. Even though the interactions in institutional systems may initially seem contrived, there are some advantages to interactions being controlled and structured. From these interactions, staff may build a safer environment and better relationships with youth.
Safety and Protection. Good observation helps to create a safe environment. Information about potential assaults, escapes, or other dangerous behavior flows from good observation skills. Understanding this information in its proper context can help staff to intervene in a timely manner and prevent harmful behavior. This type of proactive strategy increases the safety of staff and residents.
Legal and Ethical Obligations. Staff have a legal and ethical obligation to accurately observe both appropriate and inappropriate behavior. Issues such as continued confinement, treatment and placement planning for youth, discipline of staff, or even litigation depend on accurate observations. The risk for staff of being sued or being found liable in a lawsuit can be mitigated when staff carefully observe and document behaviors.
What to Observe
The subject of observation is the behavior of confined youth. That behavior differs from verbal expression and is the focus of this chapter.
The categories of nonverbal behavior staff should observe are called kinesics, paralanguage, proxemics, physical characteristics, and contextual factors.
Kinesics. Kinesics is the study of body and muscle movement. Kinesics is concerned with the meaning of these body and muscle movements within the facility setting, which is probably one of the clearest forms of nonverbal behavior.
Most people readily recognize clinched fists, arched shoulders, a frown, and a set jaw as nonverbal signs of aggression, hostility, or anger. It is important to note that the skillful observer looks for patterns of behavior that characterize what is typical for each resident. Changes in typical patterns can indicate a problem.
Paralanguage. Paralanguage is concerned with the vocal qualities that affect the auditory senses. These qualities include whispering, shouting, accents, tones of voice, or speech impediments. Effective observation requires that staff watch residents frequently and long enough to establish each youth’s patterns of paralanguage. Again, deviation from individual patterns provides meaningful information.
Proxemics. Proxemics is concerned with the position of people in the environment and in relationship to others. Everyone is familiar with the concept of personal space, which is an issue of proxemics. Other relevant nonverbal behavior include touching and eye contact.
Facility staff members need to be sensitive to the issue of proxemics. Although touching is an effective way to communicate feelings between staff and residents, it must be done carefully and in response to patterns of behavior. The invasion of personal space by another youth or by a staff member is often viewed by hostile youth as inappropriate touching or as a sign of aggression.
Physical Characteristics. Physical characteristics often provide the greatest insights about a youth’s successful adjustment to a facility. Issues such as clothing and hair and how youth choose to wear them; jewelry, physical size, hygiene, and tattoos communicate much about an individual. Within the institutional setting, the admissions process deliberately imposes conformity. For example, in most confinement facilities, residents must wear institutional clothing. However, youth modify even their uniforms. They express and distinguish themselves through such modification, which along with basic hygiene and self-care may indicate a youth’s adjustment, attitude, and state of mind. Efforts by youth to individualize their appearance may reflect that youth’s level of confidence, rebelliousness and values, or emotional states such as depression, fears, and beliefs—whether real or imagined.
Contextual Factors. Contextual factors are the physical and social environment in which behavior occurs. The key here is “fit” or congruence between physical and social environments. Consistency among time, place, social circumstances and behavior characterize the behavior setting. Does the behavior fit the context in which it is exhibited?
One example is a funeral service. Many behaviors are associated with appropriate conduct at a funeral. It would be unusual to see someone attending a funeral dressed in football gear, wearing a team jersey and waving a foam “we’re number one” hand. This behavior would be worthy of careful observation because it does not fit the context.
Through their daily routine and procedures, juvenile detention centers, juvenile correctional facilities, and adult facilities that house youth each establish certain expectations for behavior in different physical and social environments within the institution. Therefore, each facility encompasses several contexts (education, recreation, group counseling, court). Good observation helps staff understand whether youth behavior is appropriate to the context.
Early one morning, while serving breakfast, one of the facility’s cooks noticed a youth moving erratically around the room, talking and laughing loudly, poking and teasing his peers, and ignoring his meal. She noticed that he was unkempt and had not combed his hair. She knew the boy as normally quiet, timid and obedient. She reported her observations to a staff member. Thorough investigation revealed that his mother had provided him with methamphetamine when she had visited the night before. The cook’s observations, both during that breakfast service, as well as on numerous prior occasions, provided important information. Her observation was based on changes in the boy’s body movements (kinesics), his uncontrolled and inappropriate laughter (paralanguage), his physically irritating his peers (proxemics), his messy appearance (physical characteristics), and his failure to sit and eat his breakfast as the facility rule required (contextual factors.) Good observation skills can be learned by anyone; it does not require an advanced college degree. In fact, good observation skills must be considered a component of all jobs in facilities that serve youth. Our cook provided everyone a good example.
How to Observe
What skills are associated with good observation? This section is the “how to” part of the training objectives. Although there are many different opinions about what constitutes good observation skills, the focus here will be on four primary skills for workers in any confinement facility serving youth: attention, awareness, objectivity, and positioning.
Attention. Attention involves remaining alert to the relevant behavior and cues within one’s sensory field—the distance one can see and hear. Human beings are able to attend to very few of the relatively thousands of stimuli that constantly bombard them. Thus, the attentive staff member must select and focus on the relevant stimuli. In most instances, attention is directly related to the staff member’s mental and physical alertness.
Working in an institution is a stressful job. Working with troubled youth and insufficient resources can create difficult situations for staff—which often lead to the temptation to use alcohol or drugs as a means of relaxation or tension reduction. The juvenile justice and corrections professions are ripe for substance abuse problems, which severely curtails attention and alertness.
Shift work can be disruptive to the employee’s sleep patterns and often interferes with his or her personal life, aggravating job stress. In addition, when an employee works overtime, it is even harder for the employee to be sufficiently rested. Being overly tired from working extended hours and losing sleep makes employees less vigilant and alert.
The National Partnership for Juvenile Services (NPJS) addresses this issue in its Code of Ethics. Concerned about the potential threats to resident and staff safety inherent in a confinement setting, NPJS calls for the juvenile services professional to “take responsibility for maintaining their physical and psychological wellness in order to provide optimal levels of safety, security, and helpful services for youth in their care.”
In addition to the safety threat from substance use, youth that have grown up with adults who use and abuse substances will recognize a staff member’s abuse problem. Such recognition is likely to cause youth to lose trust and confidence in those adults and view them as hypocrites.
Awareness. The skillful observer seeks to understand human behavior and individual interaction with the environment. Because behavior is usually purpose driven, the worker that remains informed of pertinent facts about both confined youth and the physical environment maximizes his or her ability to observe, predict, and respond appropriately to a variety of unexpected situations.
Awareness is entirely dependent on the direct care worker’s willingness and ability to obtain more information about confined youth. Staff can enhance their awareness of each youth under his or her supervision by reading anecdotal logs, psychological reports and legal and social files (when available). Staff should discuss this information and current behavior with staff on previous and upcoming shifts and with other key players such as clinicians, teachers, and parents. Awareness comes from a proactive effort to obtain information about a youth that may then be used to understand or predict his or her behavior.
Objectivity. All sensory input must be filtered through one’s emotions, values, and past experiences. Therefore, objectivity is accomplished only by keeping personal biases from interfering with the ability to perceive reality. Staff must make a conscious effort to be honest with themselves and to recognize their own limits and fallibilities. However, with practice and perseverance, a careful observer is able to set aside personal filters and view behavior professionally, without prejudice. In this manner, one must approach the role as a professional, with the understanding that the job is to promote long-term growth for youth.
Biased interpretations do not simply go away. Objectivity as an observational skill must be practiced. Practice occurs through giving and receiving feedback by formally or informally consulting with a supervisor or trusted co-workers. To be objective, staff must discuss their feelings about confined youth, their offenses, and their behavior. Staff must analyze these feelings openly, in the presence of coworkers or supervisors who have the ability to recognize personal prejudices that may interfere with the provision of effective care. To become more objective, staff must interact with peers and must work to become more self-accepting and less judgmental or condemning. In addition to being open to receiving feedback from others, staff members must be willing to listen non-judgmentally and offer opinions humbly.
Positioning. It is essential for facility staff to physically position themselves in a manner that maximizes the opportunities for observation. Staff should be situated so that all youth are in plain view—which is ideally accomplished by developing skills as a participant observer. Participation helps develop healthy relationships with youth, without appearing to be a guard or a watchdog. Conversely, staff must take care to avoid becoming so involved in a simple activity that they lose sight of the responsibility to observe the behavior of the entire group. The rule of thumb for position skills is “You can’t observe it if you can’t see it.”
To develop the skill of effective positioning, many trainers will identify floor plans of detention facilities and ask participants to place staff members in the most strategic positions. As staff members assume responsibility in the facility, those staff members should do the same thing within each living or activity area with newer peers. In fact, it is beneficial to complete this exercise as a team activity. New and junior staff should ask advice of senior staff for both routine and non-routine activities, or special activities that may occur just one time. Positions should be a part of planning special events and activities or responding to problems.
Electronic Surveillance. In addition to the four observation skills discussed above, most facilities have some kind of camera monitoring system that may aid in observing confined youth. However, it is important to understand that cameras and video recording systems must not be used in place of direct observation. Cameras and recording systems are useful tools for confirming direct observations by staff. The video record can provide helpful information when there is a review or investigation of an incident or of youth behavior. The record can offer protection to staff members who are fraudulently accused of misbehavior or serve as oversight to help ensure youth safety and security. Video recordings may never replace the staff member’s written documentation of their observations.
Why Recording Is Important
The recording of information in juvenile detention, juvenile correctional facilities, and adult confinement facilities that house youth is important for two basic reasons—documentation and communication.
Documentation. Documentation is written communication that includes a message, a sender (the writer), and a receiver (the reader). The sender must always be aware of the receiver when completing documentation. We document to ensure that there is a durable record of what has taken place. We document so that necessary information can be shared among staff. And, we document to ensure the safety of youth and staff. Documentation supports internal and external quality assurance activities and, ultimately, safety and security. Quality assurance includes administrative monitoring of incidents and of employees’ handling of those incidents. It also includes audits from government oversight parties or other review bodies such as the American Corrections Association (ACA). (See Ch. 17: Quality Assurance)
Documentation provides a written account of events. Because memories are faulty, and because accuracy deteriorates over time, it is best to write the description of behavior as soon as possible. In some institutions, staff are automatically provided with time off the floor after a significant incident to complete their documentation. The general expectation is that reports must be completed before the staff member’s shift ends.
Aggregated information from documentation over time can help in the evaluation of program effectiveness and individual resident progress.
Documentation provides a sense of accountability. Knowing that behavior must be recorded, staff are much more likely to pay attention to specific behavior and to improve their observation skills. Further, residents quickly understand that the staff keep comprehensive records of their behavior. Hence, residents tend to become more accountable.
One of the most important purposes of documentation is to help staff solve problems whenever serious, dangerous, or illegal behavior occurs. Documentation serves as evidence that action was taken. It may be the critical factor in helping to reduce liability among correctional staff. Legal experts maintain that documentation is the single most important issue in establishing a good faith defense.
Communication. Working with youth in confinement facilities is a complex job that requires an effective exchange of information among line staff, administrators, treatment providers, legal counsel, family members, and others. Decisions about youth are only as good as the information on which they are based. Therefore, communication is a primary function of documentation.
Staff members that work with youth in facilities usually do not have an opportunity to interact with all of their coworkers on a daily basis. Written communication becomes essential to ensure consistency among staff members and continuity from one shift to the next. Information can also flow to other interested parties, such as therapists, attorneys, probation officers, and judges.
A record of observations also promotes continual improvement in observation. It gives staff members a baseline perspective from which to view resident behavior. It may be used to update new staff on issues and problems that are affecting individual residents. In this manner, documentation serves to promote program consistency, which is key to effective programs.
What to Record
Recording is an attempt to answer the questions of Who?, What?, When?, Where?, and How? This simple approach helps to define those issues that should be committed to writing. One caution is necessary about this journalist’s list: statements about the reasons for a youth’s behavior (the why) should generally be avoided. It is not the responsibility of direct care staff to affix motives to a youth’s behavior or to determine his or her intent. Instead, these questions should be referred to administrative staff or to a team discussion supervised by a qualified staff member.
In answering the six questions above, the following guidelines should be considered:
- was involved?
- discovered the incident?
- witnessed the incident?
- took what actions?
- was in possession of what?
- was notified?
- was the youth’s complaint?
- property was involved?
- actions did the youth take?
- were the results of those actions?
- automatic systems were involved (alarms, automatic sprinklers)?
- was said?
- evidence was found and collected?
- equipment was used?
- equipment or furnishings were damaged?
- follow-up is required?
- did the incident occur?
- was evidence found?
- were staff members and youth located?
- did the incident happen?
- was the incident discovered and reported?
- did various staff members arrive?
- did back-up help arrive?
- was the incident brought under control?
- did the incident occur?
- was the incident discovered?
- was information obtained?
- did the incident occur (accidental or intentional—factual, no opinions)?
- do you explain the actions that you did (especially if you deviated from the agency’s policies)?
Required documentation is determined by the facility and may vary, based on the type of facility and the requirements of the jurisdiction or parent agency. However, most facilities that serve youth have some basic documentation requirements, which often include anecdotal logs and special incident reports. In addition, there may be specialized reports for particular types of facilities or specific kinds of incidents.
Treatment Plans and Progress Reports
Youth correctional facilities are secure, long-term, post-dispositional, residential programs where youth are held to ensure the community’s safety while they receive treatment to prepare them for eventual release. Treatment and service objectives are clearly defined in service and treatment plans. (See Ch. 15: Service and Treatment Plans) Those plans may be developed by a clinician or by a multi-disciplinary team. Generally, the facility has a format for such plans. Progress towards achieving the objectives in plans must be clearly documented on a regular basis. Service and treatment plans and progress reports must comply with the same writing expectations for incident reports discussed below, following the agency’s preferred format.
In addition to special incident reports, completed when an unusual event occurs, facilities that serve youth must complete some documentation on a daily or shift-by-shift basis. Anecdotal logs are typically required and may be group logs, individual logs, or both.
A group log provides a general description of a group or unit during a specific period of time. These logs are generally completed at the end of a shift to record activities that have taken place, the overall mood of the group, and to ensure communication with oncoming shifts.
An individual log is also completed at set intervals, again usually at the end of a shift, for the same purpose. But, an individual log offers more detailed information about each youth so that staff members may individualize services in accordance with a young person’s particular needs and plans. For example, a youth may have returned from a visit with a parent in which they argued or a youth may have received disappointing news at a court hearing. It is important to communicate that information so that the oncoming staff can appropriately approach and respond to that youth and to the group as a whole. To have a smooth transition, it may be important to attend to the needs and concerns of individual youth. Well-written individual logs inform staff of those needs.
Staff should record what other staff members might anticipate from residents. Consistency means that the staff members who supervise a youth during different shifts over a period of a day or more will respond to problems with uniformity. To ensure that occurs, written communications must describe what has happened and, based on specific observations, what staff members think may happen in the future.
Records are also important to describe what other staff members have done to help youth. Part of the responsibility of recording is to note details of staff behavior.
Good records indicate clearly which interactions or interventions have been successful and which have not. Records are the best indicator of program effectiveness.
The ACA correspondence course for juvenile care workers offers several useful criteria that may help the staff member complete log entries that are clear, concise, and accurate. These criteria provide a list of themes that direct-care workers might use in crafting their written communications, particularly in their logs. The following are the ACA criteria, with an example of each:
Communication: “I talked with Greg about his shouting and cursing.”
Observation: “Nate shuffles his feet and looks downward when I ask him about his visit with his parents.”
Intervention: “Mr. Carlson and I physically restrained Patrick and took the knife from him.”
Feedback: “Dr. Richards said we need to pay close attention to Derrick since his latest suicide threat.”
Specificity: “A verbal argument between Tracy and Pam occurred in Dorm C at 4:00 p.m.”
Significance: “Juan and Pete had a fist fight in the recreation room at 10:00 a.m.”
Facility staff members have a natural tendency to complete paperwork as quickly as possible. They may believe that doing so is efficient and allows them to spend more time with youth. Unfortunately, they may hurry because they want to complete their assigned work and leave their shift or because they simply do not enjoy doing paperwork. When reports are completed too hurriedly, problems arise and quality deteriorates. Without comprehensive information, the reader cannot make competent decisions on behalf of a youth or a group. Completing logs in a superficial manner may indicate a passive resistance to paperwork, or that staff do not view it as relevant or appreciated by administration. If a line staff member questions the value of his reports, he should bring concerns to administrators. And, administrators should not take quality reports for granted, but should offer positive feedback while consistently monitoring for content and quality. A poorly written log simply makes the writer appear unprofessional. The writer does not want to justify sloppy work that provides insufficient information. Paperwork may be the most important issue in helping staff members protect the rights of detained youth and protect their own careers.
Before each shift ends, the line staff in the unit must make written notations in each youth’s file. One line staff member regularly manages to complete his assigned files expeditiously and punch out on time. His files typically include information for the next shift like “GDNP.” Fortunately, his peers on the following shift know that GDNP means “good day, no problem” but they certainly do not know what a specific youth has done on that shift, and how his behavior has not led to any problems. They have no detail, and they do not know if there were no problems for the staff or for the youth. They couldn’t tell you what was good about the day. Did that youth participate actively in planned programming and activities? Did he go to court and learn that he is getting released? Did he stay in his room and avoid interacting with staff or other youth? If so, could he be depressed? And, if so, and he attempts to harm himself, does the line staff member who so efficiently wrote “GDNP” want to explain the attempt to administrators, investigators, attorneys, or that youth’s parents?
Guidelines for writing special incident reports are applicable to all documentation in facilities that serve youth. However, because incident reports are more formal, stand-alone documents, they are more likely to be read by others. Although direct care staff usually complete anecdotal logs, any staff member or other individual present when an incident occurs must complete an incident report.
For our purposes, an incident report is defined as a written summary of events or information that the author has seen, heard, or investigated and provides a permanent record of those events or information. In a juvenile or adult confinement setting, a report is a permanent record of an incident that someone in authority can use as a basis for various actions.
Incident reports have many uses, for example to accompany other documents to the court from a juvenile detention center, a juvenile correctional facility, or an adult facility that serves youth. They may supplement reports and recommendations to paroling authorities for youth in juvenile correctional facilities or in adult facilities. Attorneys that represent youth or the agency in litigation may request them. Quality assurance bodies, such as state monitoring units and external auditing entities, review them to verify compliance with standards. They may be used to justify changes to policy and procedure. They may be used to improve safety and security on the job. They may be used to compile statistics or other important information. They may be used to refresh the memory of those involved in an incident. They may be used to evaluate an employee’s performance and potentially initiate discipline or additional training. The use of incident reports in teaching and training of staff is a worthwhile, evidence-based practice. A poorly written incident report makes the writer appear unprofessional and can reflect negatively and have an adverse effect on the facility.
Suicide Screening, Assessment, and Monitoring Reports
Suicide screening, assessment, and monitoring are discussed separately because they have crucial and unique components. Although the same rules apply to suicide prevention documentation as to incident report writing, those rules become even more critical when dealing with situations that are literally matters of life or death.
Suicide assessment is not seen as a single event but, rather, an ongoing process. According to the definitive National Center on Institutions and Alternatives research study by Lindsay M. Hayes, youth can become suicidal at any time, including at initial admission, after adjudication when returned from court, after receipt of bad news, after suffering some kind of humiliation or rejection, during confinement in isolation, segregation or time-out, or following prolonged periods of detention. Suicide screening may be part of the medical intake screening or may use a separate form or process. That screening should, at a minimum, include questions such as the following:
- Was the youth a medical, mental health, or suicide risk during any prior contact and/or confinement within the facility?
- Does the arresting and/or transporting officer have any information (from observed behavior, documentation from the sending agency or facility, conversations with family members) that indicates the youth is a medical, mental health, or suicide risk now?
- Has the youth ever attempted suicide?
- Has the youth ever considered suicide?
- Is the youth currently or has the youth ever been treated for mental health or emotional problems?
- Has the youth recently experienced a significant loss (relationship, death of family member, close friend, job, pet)?
- Has a family member or close friend ever attempted or committed suicide?
- Does the youth feel there is nothing to look forward to in the immediate future (expressing helplessness and/or hopelessness?)
- Is the youth thinking of hurting and/or killing yourself?”
Several Intake Screening and Assessment forms are available for the identification of suicide risk, including “The Intake Screening form/Suicide Risk Assessment,” the “Juvenile Risk Assessment,” and the “Massachusetts Youth Screening Instrument—MAYSI-2.”
Confinement, whether in a juvenile detention center, a youth correctional facility, or an adult facility that houses youth, is in itself considered a risk factor for suicide. Therefore, all confined youth should be viewed as at risk. It is important to observe confined youth for suicide potential throughout their stay in a facility and to document all observations. “Other supervision aides (e.g., closed circuit television, companions/watchers, etc.) can be utilized as a supplement to, but never as a substitute for, these observation levels.”
Communication between direct care personnel and other professionals in the facility regarding observation for suicide potential is critical. Communication should occur between each shift, during shifts, and between line staff and administrative and/or clinical staff. To ensure that communication occurs, observations must be recorded on designated forms and distributed to all appropriate staff.
In addition, staff members in juvenile detention centers, juvenile correctional facilities, and adult confinement facilities that serve youth must document regular, visual checks of youth, their status, behavior or affect, and other observations at required intervals. Those checks should be random, and their frequency should be based on the youth’s assessed potential for suicide and on the requirements of the facility’s suicide prevention policy. When it is determined that a youth is at imminent risk and is placed on constant suicide watch, that youth must receive one-on-one monitoring on a continuous, uninterrupted basis.
Completing suicide screening, assessment, and monitoring documentation is literally a life or death mandate. Failure to record accurately may not just result in employee discipline or a lawsuit; it could mean a child’s death. (See Ch. 11: Mental Health)
Electronic Monitoring Devices
Many facilities use electronic wand systems to help ensure that room checks are conducted as required. These wands scan strategically located checkpoints located near resident rooms and other areas in the facility where checks are required. Recorded information from the scans is then electronically downloaded where it can be used to verify timely resident checks, monitor staff performance, and provide feedback to administration. Some electronic monitoring systems also allow the staff to enter comments about their visual observations of what the youth is doing (e.g., sleeping, sitting up, pacing).
The completion of repeated and frequent room checks can become monotonous and, sadly, human nature may lead even conscientious workers to take short cuts. Electronic systems can be an aide to managers and a motivator to security staff, as they require that staff go to the checkpoints at the times specified for the required watch.
It must be emphasized, however, that scanning a checkpoint must not replace visually checking on a youth. There must also be written documentation of the visual checks that describe the youth’s behavior and affect. If the electronic system includes coding of typical behavior, the staff may only be required to separately document unusual behavior or circumstances. If the electronic system only records the scan, staff must also record their observations. An electronic monitoring system must be viewed only as a supplement to required visual observations and recording of those observations. Additionally, required room checks must be random and must be documented accurately as they occur, not as they are planned. The use of forms with pre-printed times for room checks undermines the purpose of staggered inspections.
Each facility has unique documentation requirements along with reports and forms designed for the entire agency. Those reports may include such things as documentation of required checks of confined youth, search reports, mandatory reporting of suspected child abuse and neglect, and periodic head counts. Reports must comply with agency policy and procedure and state statute. However, the basic rules for incident report writing discussed in this chapter are equally applicable to all type of reports.
As discussed above, incident reports are stand-alone documents that may be used for many purposes. They may be read by parties within the facility and by external stakeholders. The importance of a well-written incident report or other required report cannot be overstated. High-quality reports are
- Written in plain English.
- Accurate and specific.
- Well organized.
- Grammatically correct.
- Free of jargon and abbreviations.
Reports must be written in plain English. Because the purpose of recording and report writing is to document and communicate observations, statements must be understandable to others. It is not necessary to impress coworkers with one’s vocabulary skills. Avoiding slang, flowery terms, and psychological jargon maximizes one’s clarity. No one cares if a youth makes “a ubiquitous olfactorial assault,” but it is noteworthy to record that the youth has body odor.
Accurate and Specific
A report may contain factual errors due to incomplete fact gathering or simple typographical errors. That may not be problematic initially but could haunt a worker later if a youth submits a grievance or, more seriously, if a report becomes part of a lawsuit. No information should be included in a report that has not been established as accurate. Accuracy also implies specificity. Vague references provide the reader little information and invite interpretation. A specific description of a resident’s behavior is more useful to the reader than a label or a generalization. For example:
Vague: Bobby was hurt in a fight.
Specific: Johnny pushed Bobby to the floor face first and Bobby’s nose was bleeding heavily.
A good report includes statements that are real and can be either proved or disproved. Inferences are related to facts in that they are conclusions based on reasoning. Inferences become sound when they are supported by facts.
Inference: Bobby was crying after his court hearing and should be watched closely in case he is suicidal.
Fact: Bobby told me that he plans to kill himself rather than go to state school.
Reports must support inferred conclusions. Professional and clinical staff or teams may generate hypothetical conclusions about resident behavior. Otherwise, unsupported conclusions have little practical value in facility settings. By providing specific behavior observations, the record supports the inference or a different conclusion.
A well-written report must be fair and impartial and not influenced by opinion. The writer should avoid using words that change the tone of the report. All sides of a story should be presented and no one side should be favored. A report may include statements from involved parties, but the report should make it clear that those statements are quotes.
Records must be completed in a timely manner to be of maximum value. The completion of forms varies with the type of document being considered (e.g., incident report, anecdotal log). However, the goal is to provide the specific information required for each form as soon as possible. Timeliness is a constant concern. Documenting observations while the information is fresh and recall is at its optimum enhances the accuracy of the recording. Generally, reports must be completed before the writer leaves the shift.
A well-written report covers the Who? What? Where? When? How? It does not leave unanswered questions. The writer should consider how the report might be used in both the short and the long term. If the writer puts information in the report, he or she will not have to rely on memory. Many parties could eventually read a report including people the writer may not have considered when writing the report. In addition to other line staff, facility administrators, and clinicians, others could read a report, such as disciplinary bodies, attorneys, judges, journalists, and even the public. It is safer to include factual details in a report than to leave them out and attempt to recall them later. Doing so could embarrass the writer and the agency.
Although we just emphasized writing a complete report, doing so does not preclude writing concisely. Do not omit important details but use words economically. Reports must be brief, concise, and pertinent. Documents should present the most relevant information in the most efficient manner with the greatest possible clarity.
An agency may have a required format for incident reports that staff should follow. If there is no agency requirement for structuring a report, the writer should plan before beginning to present information in a logical order. Often, simple chronological order can work well.
A well-written report is unambiguous and understandable. Multiple readers should be able to reach the same conclusions when reading a clearly written report.
Vague: The unit was overcrowded when the fight began.
Clear: There were 25 youth in the unit that had a rated capacity of 15.
The writer may even use diagrams or sketches to help illustrate what he or she is describing.
A well-written report complies with basic rules of grammar, spelling, and punctuation. Some important guidelines to follow include:
Write in the first person. Writing in the first person when discussing the writer’s role and actions makes the report easier to follow. Use of the third person in that case is more formal and less acceptable.
Write in the past tense. The incident occurred in the past, and the report is clearer if written that way.
Avoid the emphatic form. Saying: “I did complete my room checks” rather than simply saying, “I completed my room checks” suggests that the writer is trying to justify behavior and can raise questions about whether something actually did occur.
Always use antecedents for pronouns. A report must be clear about to whom or to what it refers. Pronouns must agree with their antecedents in number (singular or plural.) “Mr. Smith and Bobby got into an altercation and he started yelling” leaves the reader uncertain about who was yelling. “Carlos threw the ball at the other group of youth and they started fighting” doesn’t clearly tell the reader who started fighting, Carlos and the group or just the other group of youth.
Spell correctly. Spelling errors are simply not acceptable. If reports are hand-written, the writer should use a dictionary to ensure correct spelling. Fortunately, many facilities now have computer-generated reports, and the writer may use the spell-check function. The writer should still proofread the report. A word may be spelled correctly and not be the word that was intended by the report writer (e.g., leaving off the “e” and writing “us” when “use” was the word intended). Poor spelling reflects sloppiness and may imply that other aspects of a report were completed carelessly. Poor spelling can suggest lack of education, intelligence, and professionalism.
Use the active voice. The writer should use the active voice whenever possible. Active voice is more direct and efficient. “Bobby pulled the fire alarm” is easier to understand than “The fire alarm was pulled by Bobby,” and the latter version adds extra words. The former, active version does a better job of highlighting the subject of the sentence—Bobby. The passive voice tends to de-emphasize the person responsible for the action. The report writer should examine his or her sentences to see if it is clear who has performed the action.
Avoid Jargon and Abbreviations
Each profession has its unique terminology or jargon, which may save time in recording but which also leaves questions for readers. Some jargon may also impact the report’s objectivity. “We treated Bobby no differently than any other perp.” The word “perp” suggests the writer has made the assumption that Bobby is guilty. And, perp is certainly jargon that reflects a lack of professionalism in an official report. Abbreviations can also be confusing and misunderstood by a reader. Professions, jurisdictions and facilities all have abbreviations that they commonly use that outsiders may not understand. The term “GDNP” may not mean “good day, no problems” to everyone who reads the log entry. “We referred him to CMH for a psych eval” does not tell an unfamiliar reader where the youth was referred and whether the referral was for a psychological or psychiatric evaluation. A medical professional may use the abbreviation “pt.” to refer to a patient while a mental health clinician who works with children and youth may use that same abbreviation to refer to a parent. However, it is acceptable to use common abbreviations such as Mr., Ms., and Dr. An abbreviation may be used if it is defined in the report: “the National Partnership for Juvenile Services (NPJS).” The full term should be used with the first use of the abbreviation.
Reports must be legible. Regardless of how accurate or useful an observation may be, it has no value to others unless it is recorded legibly. Many facilities now require that reports be computer-generated. In addition to typed reports being more legible, they are more professional in appearance. They can be written on an agency-mandated template that helps to ensure that reports are complete. The use of a computer can help catch spelling and grammatical errors and highlight jargon or abbreviations that may need to be revised. Electronic reports may be quicker and easier to complete. If a facility does not use computers to create reports, or uses them for just some types of records, the writer must ensure that his or her reports are readable.
Records must be protected from unauthorized disclosure. To protect each resident’s right to privacy and to prevent misuse of documents, all information about residents is held in confidence. Policy and procedure should specify the circumstances under which information about residents may be released. Policy and procedure should be in accordance with state laws governing confidentiality. Information may be released only with proper authorization. Although electronic records may provide a number of advantages, they are also subject to confidentiality breaches, and agencies must implement procedures to maximize their safety, just as is the case with paper records.
All employees of juvenile detention centers, youth correctional facilities, and adult confinement facilities that house youth must receive training on behavior observation, recording, and report writing. Any staff member could be called upon to document his or her observations through a facility’s required reporting. Each staff member or other individual present at the time of an incident must complete a report. Therefore, all facility employees should be trained on basic observation skills, facility reporting requirements, and writing an incident report. That training should occur as part of the agency’s initial employee training program. Ongoing instruction should also focus on report-writing skills and quality documentation. Administrators must be willing to reject poorly written reports. A supervisor should offer feedback, constructive criticism, guidance, and support to help employees improve their written documentation. Training should also address confidentiality laws and policies, mandatory child abuse and neglect reporting requirements, and other legal and ethical implications of behavior observation, recording, and report writing.
The job responsibilities for staff in facilities that confine youth include a broad range of activities. The science behind working with troubled youth draws its principles from various disciplines. It is complex and interdisciplinary. Various skills are needed to perform the job competently, including behavior observation, recording, and report writing; all of these skills can be taught and learned.
Working successfully with youth, regardless of the facility setting, is a function of good information that supports insightful planning. Good information permits staff to monitor and adjust daily interventions with youth to maximize effectiveness. Good information helps staff to operate a consistent program that simultaneously reduces the need for punishment. For staff who work in youth confinement facilities, the foundation of good information is proficiency in behavior observation, recording, and report writing.
Firebelle Productions. 2006. “Writing Effective Incident Reports.” http://www.firebelleproductions.com/newsletters/ReportWriting2013.pdf.
Galloucis, M., and H. Francek. 2002. “The Juvenile Suicide Assessment: An Instrument for the Assessment and Management of Suicide Risk with Incarcerated Juveniles.” International Journal of Emergency Mental Health 4, no. 3: 181–199.
Grisso, Thomas, and Richard Barnum. 2000. The Massachusetts Youth Screening Instrument-2: User’s Manual and Technical Report. Worcester, MA: University of Massachusetts Medical Center.
Hayes, Lindsay M. 1999. Suicide Prevention in Juvenile Correction and Detention Facilities: A Resource Guide. South Easton, MA: Council of Juvenile Correctional Administrators.
Hayes, Lindsay M. 2009. Juvenile Suicide in Confinement: A National Survey. NCJ 213691. Washington, DC: Office of Juvenile Justice and Delinquency Prevention. https://www.ncjrs.gov/pdffiles1/ojjdp/213691.pdf.
Hayes, Lindsay M. 2011. “Guide to Developing and Revising Suicide Prevention Protocols Within Juvenile Facilities.” National Center on Institutions and Alternatives. http://www.ncianet.org/wp-content/uploads/2015/05/Guide-to-Developing-an....
Jepsen, B. 1998. “Supervising Youthful Offenders.” (Correspondence course). Lanham, MD: American Correctional Association.
National Partnership for Juvenile Services. 2012. “Code of Ethics,” https://www.coursehero.com/file/103143044/NPJS-Code-of-Ethicsdoc/.
New Jersey Department of Corrections. 2004. “Report Writing for Corrections,” Lesson Plan: 5.
 National Partnership for Juvenile Services, “Code of Ethics.”
 Firebelle Productions, “Writing Effective Incident Reports."
 B. Jepsen, Supervising Youthful Offenders (Correspondence course), (Lanham, MD: American Correctional Association, 1998).
 New Jersey Department of Corrections, “Report Writing for Corrections,” Lesson Plan, (2004): 5.
 Lindsay M. Hayes, “Guide to Developing and Revising Suicide Prevention Protocols Within Juvenile Facilities,” (National Center on Institutions and Alternatives, 2011).
 Hayes, “Guide to Developing and Revising Suicide Prevention Protocols,” 2.
 Lindsay M. Hayes, Suicide Prevention in Juvenile Correction and Detention Facilities: A Resource Guide, (South Easton, MA: Council of Juvenile Correctional Administrators, 1999).; M. Galloucis and H. Francek, “The Juvenile Suicide Assessment: An Instrument for the Assessment and Management of Suicide Risk with Incarcerated Juveniles,” (International Journal of Emergency Mental Health 4, no. 3, 2002): 181–199.; T. Grisso and R. Barnum, The Massachusetts Youth Screening Instrument-2: User’s Manual and Technical Report, (Worcester, MA: University of Massachusetts Medical Center, 2000).
 Hayes, “Guide to Developing and Revising Suicide Prevention Protocols,” 3.