Lost in documentation: a study of case-formulation documentation in letters after outpatient assessment

The authors sought to find out how frequently case-formulation is documented by psychiatrists after initial assessment in an outpatient clinic.

Assessment letters for 150 new referrals/new referrals to a psychiatric clinic in Rotherham, U.K. were examined for the presence or absence of a case-formulation, as well as the different sections of the psychiatric history.

A group of 150 assessment letters were selected and examined. An overwhelming majority (94%) of letters did not include any case-formulation; this finding was not affected by the grade of the doctor.

Although case-formulation is considered an important skill by various training bodies, it seems that this is rarely translated into daily clinical practice. The authors discuss the possible reasons for this deficiency and discuss potential solutions.