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Formulation guide
> Present state and diagnostic frame: [Current syndrome/problems, course, function and important alternatives.] > Explanatory synthesis: [Selected context] may contribute through [supported process]. The evidence is [observation/report]. [Alternative] remains plausible because [reason]. > Strengths and preferences: [Actually elicited resources, goals and what the person considers helpful.] > Risk and next steps: [Current change, scenario, available resources, action and uncertainty.] > Revision: [What additional information or observed outcome could change the formulation.]
This is an optional clinical-note format. For OCA/IOCA use, keep the explanatory formulation, diagnostic statement, management and prognosis in the required assessment structure instead. S02
Case evidence: what was seen or reported, by whom and when. Interpretation: the possible process, explicitly marked as inferred. Alternative: another explanation for the same facts. Counterevidence: what currently weakens the hypothesis or would do so. Implication: an assessment question or proportionate action. Uncertainty: specific missing information, not a fabricated confidence percentage.
Supplied fictional facts: an adult reports panic in a crowded waiting room, immediate relief after cancelling and increasing restriction of appointments. They also report difficulty affording transport. No assessment of trauma history, diagnosis or suicidal thinking has been supplied.
Example synthesis: “Appointment avoidance may be partly maintained by immediate relief from anticipatory anxiety. This remains a hypothesis because transport cost is also an active barrier. The next step is to clarify the practical barrier and collaboratively examine what makes attendance difficult. The available information does not establish a trauma history, an anxiety disorder diagnosis or suicide-risk status.”
Why this is preferable: it retains the proposed relief loop without turning cancellation into proof of fear maintenance or inventing case history. A safety plan, diagnostic assessment or exposure programme would require additional information.
Supplied fictional facts: a person has new referential beliefs and voices after several nights of very limited sleep and recent stimulant use. Family report deterioration from baseline. Examination, investigations and the longitudinal relationship to substance use are incomplete.
Example synthesis: “The current presentation is an acute psychotic syndrome requiring diagnostic and medical assessment. Sleep disruption and stimulant exposure are temporally relevant contributors, but the available history does not determine whether the syndrome is substance-induced or independent. Family collateral can help clarify course and baseline. A biological theory such as aberrant salience should not be documented as an established patient-specific mechanism.”
Why this is preferable: syndrome, contextual contributors and a theoretical explanatory model are kept separate. The example does not use speculative neurobiology as a reason for a particular medication or legal decision.
Supplied fictional facts: a person reports feeling dismissed after receiving inconsistent instructions from two clinicians. They become angry and distrustful. Staff disagree about how to respond. No longstanding relational pattern or developmental history has been supplied.
Example synthesis: “The current rupture follows an identifiable communication failure. Distress and team polarisation should first be understood in that context. A broader attachment or psychodynamic hypothesis would require longitudinal evidence and exploration of the person’s account. Consistent communication and acknowledgement of the service contribution are reasonable immediate steps.”
Why this is preferable: it does not label justified anger as splitting, infer childhood trauma or use an assumed defence to discount a complaint.
| Avoid as a stand-alone statement | Prefer a specific, testable account | |---|---| | “Manipulative” | Describe the action, context, immediate effect and what remains unknown about function or intent. | | “Poor motivation” | Describe difficulty initiating or sustaining the activity, including symptoms, cognition, access and perceived relevance. | | “Splits the team” | Describe polarised staff responses and the sequence of interactions. | | “Trauma caused this” | Identify reported exposure, temporal links, alternative explanations and the level of inference. | | “Protective family” | State who is available, what help is agreed and any limits or safety concerns. | | “Low risk, suitable for discharge” | Document current assessment, needs, changes, relevant scenarios and the rationale for the actual plan. |
These substitutions are editorial anti-stigma and documentation safeguards. They do not prohibit discussion of complex interpersonal or reinforcement processes when supported by evidence.
Caveats for this record