However, clinicians write reports for review by other clinicians. And they most often follow a specific path which was part of their training. They begin with the patient’s presentation and (subjective) complaints. Diagnostic (objective) findings follow, then a diagnostic conclusion (assessment) and finally a treatment plan.
Little wonder that others who review a report go straight to the end of the report for the bottom-line rather than labor through all the data.
A further complication, at least in the case of psychological reports, is a clinician using paragraphs to convey a single word and elaborating on superfluous data that have no bearing on the referral question. Obscure background information, unrelated educational experiences, names of past coworkers and detailed childhood and sexual experiences may have little relevance to the patient’s current complaints. Since the psychological diagnostic reports can be excessively and nonproductively long, wading through excessive data is punitive. Following can be cumbersome.
For example: Rather than a providing a lengthy description of all aspects of normal early development, the report could, instead, simply state: “Early development: No significant findings.”
What is the result of this excessively lengthy report style? People do not read the report at all.
They skip to the end to find the conclusion and recommendations without knowing the clinician’s thought process.
It is far more productive to follow the slowly evolving pattern of stating the formal diagnoses at the onset, followed by recommendations and then organizing the data that supports those findings in ensuing pages.
If an insurer wishes to know what they are paying for, it is clearly stated on the cover page. This saves unnecessary clerical time and, for the sake of the clinician, speeds billing.