Case presentation and documentation

Select facts that answer the clinical question

A useful presentation identifies the main difficulty, its course, important contextual information and the effect on functioning. Organize the history so a listener can reconstruct the sequence. Avoid a long inventory of details whose relevance is not explained.

Include the source of observations and clarify disagreements between accounts. Distinguish earlier recorded diagnoses, the person’s recollection and the current clinician’s interpretation. A coherent account should not hide uncertainty to sound more confident.

Separate description and reasoning

Present representative mental-state findings with enough description to support the technical terms used. Then explain the formulation, plausible alternatives and evidence that would help distinguish them. A summary and a formulation can be adjacent, but they do different work.

State which information could not be obtained and what remains to be clarified. Relevant absent findings should reflect an assessment that occurred. Do not copy a complete-looking negative history or normal examination when it was not established.

Use learning examples responsibly

For discussion on this website, examples must be original and synthetic. Do not transpose a textbook’s identifiable case narrative into a demonstration. Real clinical documentation belongs within an authorized record system and should not be entered into website search.

A focused supervision question can ask which missing fact would most change the formulation. This supports reasoning without presenting a website-generated diagnosis, prescription or safety judgement. Learning materials supplement supervised practice rather than certifying competence.

For your next supervision discussion

Give a short summary of a synthetic case, then a separate formulation. Ask a colleague which conclusions were supported by the description and which required an unstated assumption.