Style in Report Writing
She “suffers” from depression…
This is a layman’s comment, as in all report writing we avoid judgmental statements. Many people live with depression, but that does not mean they suffer from it. A healthier statement is they deal with it and live productive lives. Always avoid the use of the qualifier “suffer” in writing. Does someone suffer from Asperger’s Syndrome? Consider Greta Thunberg who is world famous. She self-describes being on the Autism spectrum
Similarly, an informed writer would never say Paul Nunnari is “confined” to a wheelchair. Does Mr. Nunarri, premier wheelchair racer look “confined” to a wheelchair, in this picture? Again, such a statement is judgmental and has no place in an objective psychological report. Mr. Nunnari would likely feel insulted by such a limiting statement about his abilities. BTW, it is OK to use the word “disability” in a report, or “able bodied.” However, be careful as words can hurt, so we avoid terms with long-pejorative associated meanings like “mentally retarded” which is better stated as “developmentally disabled.”
Her mood is poorly “regulated…”
There are naive people who think mood is like a thermostat, you adjust it up and down as needed. In fact, when a clinician talks about “adjusting” mood, this implies a degree of control we just don’t have in mental health. People have no thermostat! This concept comes from decades past, when psychiatrists suddenly had a new arsenal of drugs (the SSRI’s) 45+ years ago, after many years of relying on less effective medications.
It was an exciting new age, then, and these terms reflected a clinical optimism about controlling mood disorders that has just not panned out, and the terms have consequently fallen out of use in recent decades. Avoid using words like “control,” “adjust,” or “regulate” mood as you will seem like you are trying to sound like a old-fashioned psychiatrist, but instead these terms will show you are naive. Yes, it is OK to adjust a medication dose, just don’t try to incrementally adjust/regulate your happiness/sadness level with medication, or by any other means.
The patient is a white 72-year-old female…
This Sergeant Friday (“Just the facts, Ma’am.”) style works fine in a police report, but it is rather impersonal in a psychological report. Moreover, it will land you in trouble eventually. The term “female” implies biology while “woman” can mean much more; a transexual person now identifying as a woman may remain male in body morphology. Calling her “female” when she presents herself as a woman could offer a possible contradiction to her self-identification vs biological state. You can avoid this trap by sticking with man, woman or better yet, just calling someone a “person.” Do not use terms like “the patient is a white bisexual…” as revealing too much private information can be a HIPAA violation.
The patient is an alcoholic…
There is no such diagnostic term as alcoholic. DSM5 describes folks with an alcohol use disorder. Be careful in this area. Same goes for “drug addict” or addiction, use opioid use disorder, instead. BTW, always get a patient’s permission to report on their personal/private history of sex change, alcohol/drug use and rehabilitation before putting it in the Background of a report.
