Writing reports on referred individuals

These pages offer guidance for any SLTs to use when writing reports on referred individuals.

For information on writing other kinds of reports or other legal considerations such as appearing in court as a witness, view our full list of topics for Delivering Quality services

Last updated: May 2026

RCSLT Guidance Info
The RCSLT develops guidance to promote good clinical and professional practice in line with HCPC standards. Please read our statement on guidance to understand how it is developed and how to use it.
Download IconDownload as PDF
RCSLT Guidance Info
The RCSLT develops guidance to promote good clinical and professional practice in line with HCPC standards. Please read our statement on guidance to understand how it is developed and how to use it.
Download IconDownload as PDF

Introduction

 

A report is a written account designed to convey information and ideas for a specific purpose.

A report must be timely, e.g. if the SLT is making an onward referral, a report should accompany the referral.

Each report should feature has:

  • an introduction, identifying the purpose of the report
  • a middle section, which covers relevant information and actions taken or planned
  • a final section, which includes a summary, conclusions and recommendations.

The report could be:

  • an initial report following a care pathways assessment
  • a closure report at the point of discharge or transfer
  • an interim report as and when necessary, following acceptance of a referral.

Responsibilities

 

Reports fall under information governance standards for record keeping, consent and confidentiality.

Speech and language therapists, whether private, public or voluntary sector are individually responsible for following this guidance.

 

HCPC standards relating to record keeping

HCPC standards of conduct, performance and ethics – standard 10 Keep records of your work

Keep accurate records

  • 10.1 You must keep full, clear and accurate records for everyone you care for, treat or provide other services to.
  • 10.2 You must complete all records promptly and as soon as possible after providing care, treatment or other services.
  • 10.3 You must keep records secure by protecting them from loss, damage or inappropriate access.

HCPC standards of proficiency for speech and language therapists – standard 9 Maintain records appropriately

  • 9.1 keep full, clear and accurate records in accordance with applicable legislation, protocols and guidelines
  • 9.2 manage records and all other information in accordance with applicable legislation, protocols and guidelines
  • 9.3 use digital record keeping tools, where required

 

RCSLT guidance on meeting the HCPC standards provides guidance to support you in adhering to the standards of the regulator, the Health Care Professions Council (HCPC).

 

Duty of care

SLTs have a duty of care for the individual they are writing a report on and may be called to account for what they have written. SLTs are reminded that reports that are incomplete or inaccurate can mislead and have unexpected and undesirable consequences for an individual.

See also sections on Writing medico-legal reports and Writing professional advice on children.

Guidance

 

The service-user or their advocate must give consent for sharing the information contained within the report and be aware of all its recipients.

Good reports aim to:

  • support informed choice and continuity of care
  • meet legal requirements
  • maximise efficiency
  • enable effective inter- and multidisciplinary working
  • produce a complete and fully accountable reference
  • support evidence-based clinical care.

 

Hallmarks of a good report include:

  • clarity (sentence structures are short; headings are provided; jargon is avoided)
  • completeness (all relevant information is provided; the report is fit for purpose; all recipients are listed)
  • accuracy (statements are truthful, accurate and factual; sources of information are given)
  • consistency (the terminology and information is consistent and cohesive)
  • logical progression (from past to present to future; content is well-structured)
  • conciseness (details are brief but incisive and intelligible).

Once the report has been prepared in line with the principles listed above the information, grammar and spelling should be checked as well as the report date. The report, or the SLT section of the multidisciplinary report, must be signed.

Reports should be written in awareness of the information required by the recipient. Where the recipient of the report has specific communication needs, inclusive communication guidelines should be followed.

Speech and language therapists should be aware that under the Freedom of Information Act (2000) and Freedom of Information Act Scotland (2002) the service-user, parents, relative, and the police have the right to request a copy of the report.

Standards and legislation

Contributors

 

Claire Matheson, Service Lead Adult Learning Disability (2025 update)