title: Lost in documentation: a study of case-formulation documentation in letters after outpatient assessment.
abstract: OBJECTIVE
  The authors sought to find out how frequently case-formulation is documented by psychiatrists after initial assessment in an outpatient clinic.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.forename: Mohammed Juma
authors.initials: MJ
authors.lastname: Abbas
authors.forename: Lekshmi
authors.initials: L
authors.lastname: Premkumar
authors.forename: Amin
authors.initials: A
authors.lastname: Goodarzi
authors.forename: Ruth
authors.initials: R
authors.lastname: Walton
mesh_terms: D000554:Ambulatory Care Facilities; D003142:Communication; D015709:Correspondence as Topic; D004282:Documentation / Q000592:standards*; D006801:Humans; D007396:Internship and Residency / Q000592:standards; D011570:Psychiatry / Q000592:standards*; D012017:Referral and Consultation / Q000592:standards*; D006113:United Kingdom