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A Quick Guide to Clinical Writing for Psychologists

by Annie Varvaryan, PsyD | Mar 6, 2017 | Lifehacks, Tips & Advice

A man typing on a laptop.

Are there any tasks you do as a trainee, intern or psychologist that you did not expect to do before choosing a career in psychology?

One task that may come to mind is writing.

In psychology, efficient writing is a skill that is consistently required of us. Being a successful writer is a necessary proficiency to inform others about clinical matters such as patient care, reports, goals, and treatments, as well as research, statistics, and other forms of data. Oftentimes, we are not trained in professional or clinical writing and default to skills we have developed over time, which may contain common writing mistakes.

The following is a compilation of writing tips that may be helpful for a variety of clinical writing tasks for psychologists.

What is Clinical Writing?

First, clinical writing falls within the nonfiction category. In clinical writing, you want to identify who your reader is and ask yourself, “In what way am I approaching the reader? Am I a reporter? Am I making an argument?”

In clinical nonfiction writing (e.g., progress/case notes, intake reports, assessments), you are likely presenting data about either an individual person or a research idea that is objective; however, you also want to provide your own clinical judgment and opinions in a professional and effective manner. You want to be able to communicate that to the reader, not simply by repeating what the patient has told you verbatim, but by formulating the information for the reader.

You can do this by approaching your document with an involved, enthusiastic attitude and asking yourself, “What is my overall goal in presenting this information to the reader?”

Additionally, there are some basic writing principles and techniques that can strengthen any clinical document. Some of these are intuitive, but as a writer, you will find that due to time constraints, you may revert to writing habits that contain errors.

The following list provides quick and easy tips on how to improve your writing:

1. Keep Your Writing Simple

In clinical writing, it is important to clearly and efficiently communicate your impressions to your reader. Thus, it is imperative to avoid unnecessary words, jargon, or circular constructions in your writing.

Try to ensure that every word in your document serves a function; if no function is served, remove the word, and restructure your sentence. Also, decrease clutter in your writing by using the cleanest components of each word in your document.

That is, if you could use a shorter version of the word to communicate the same meaning, choose that option. For example, you could say, “Patient/client reported feeling sad at the end of the day,” instead of “Patient/client reported the saddest feelings at the end of the day.”

2. Consider Your Audience

Remember to consider your audience or reader in clinical or professional writing.

Supervisors, other professionals on your case management team, and your patients/clients may read your clinical writing. Ensure that you objectively present information that was reported to you and orchestrate your formulations in ways that are nonjudgmental toward the patient/client.

3. Choose Your Words Carefully

Words are essential tools that are combined to convey a message to the reader. Avoid the use of words that have been made up or are considered clichés, which make your writing sound colloquial (e.g., “She muscled her way through the door.”).

Use the following criteria to carefully choose words to ensure accurate grammar in your writing:

  • Do not use adjectives as nouns (e.g., “greats” versus “the great ones”).
  • Do not use nouns as verbs (e.g., “enthuse” versus “Her enthusiasm was contagious”).
  • Read everything aloud to make sure it makes sense.
  • Take out prepositions that are added onto verbs (i.e., “free up”).
  • Remove unnecessary adjectives (i.e., “tall skyscraper”).

4. Cohesion

It is important to provide a sense of cohesion and unity throughout your professional or clinical document. One form of unity is consistent pronoun use throughout the document (i.e., first, second, or third person). In clinical writing, oftentimes third person is used to communicate what the patient/client has reported to the clinician.

Another important factor for document unity is tense (i.e., past, present, or future). It is important to avoid switching tenses, except in certain cases, to maintain consistency throughout your writing.

Resources for Clinical Writing

Furthermore, learning how to implement new writing skills in your clinical writing does not have to be done on your own. There are plenty of writing resources available to you to help improve your writing and catch common errors.

The following are some resources that may be helpful in a therapist’s writing process:

  • The Publication Manual of the American Psychological Association For professional writing that involves American Psychological Association (APA) formatting, consider investing in a copy of The Publication Manual of the American Psychological Association , 6th edition. The manual provides valuable information on APA formatting, organization, writing style, reducing bias in language, tables and figures, references, and how to cite sources.
  • Purdue Online Writing Lab Additional resources on APA formatting are available on the Purdue Online Writing Lab (OWL) website.
  • Grammarly If you are looking for a resource to help with basic grammar issues, try Grammarly , a website that provides free and quick grammar checks for your document.Simply upload your document and review the suggestions for fixing common grammar mistakes. Grammarly can save you time and money and supplement professional documents with grammar, spelling, and punctuation checks. It’s not recommended that you upload clinical documents onto the website; make sure that all information you do upload is de-identified to preserve confidentiality.
  • On Writing Well: The Classic Guide to Writing Nonfiction One book that is especially useful for nonfiction writing is On Writing Well: The Classic Guide to Writing Nonfiction by William Zinsser. This book outlines principles of nonfiction writing including grammar, writing style, organization, tone, and audience in addition to methods of implementing these techniques in your writing.

Writing clearly and concisely, paying attention to grammar, and considering your audience or reader are some quick and easy ways of improving your clinical writing. When applied, these principles can help avoid common writing errors and refine your clinical writing skills.

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Greg J. Wolber

Writing Psychological Reports: A Guide for Clinicians Paperback – 1 July 2002

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The book consists of seven chapters, and begins with an overview of issues to be considered when endeavoring to write a psychological report. Such issues include the rationale for report writing, general guidelines for report writing, confidentiality and ethics, the emergence of test computerization, characteristics of the report writer. The first chapter concludes by presenting a suggested outline for reports, upon which the majority of the forthcoming text is based.

The text then delves into each aspect of the suggested outline's "pre-results" sections. Information included in this section involves report heading and demographics, reason for referral, notification of purpose and limits of confidentiality, evaluation instruments and sources of information, background information, and behavioral observations. The purpose of each section, along with an explanation of appropriate word usage and section length is given.

  • ISBN-10 1568870760
  • ISBN-13 978-1568870762
  • Publisher Professional Resource Press
  • Publication date 1 July 2002
  • Language English
  • Dimensions 15.24 x 0.64 x 22.86 cm
  • Print length 160 pages
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  • Publisher ‏ : ‎ Professional Resource Press; 2 edition (1 July 2002)
  • Language ‏ : ‎ English
  • Paperback ‏ : ‎ 160 pages
  • ISBN-10 ‏ : ‎ 1568870760
  • ISBN-13 ‏ : ‎ 978-1568870762
  • Dimensions ‏ : ‎ 15.24 x 0.64 x 22.86 cm

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Writing psychological reports: a guide for clinicians - softcover, wolber, greg j. ; carne, william f..

9780943158938: Writing Psychological Reports: A Guide for Clinicians

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  • Publisher Professional Resource Exchange, Incorporated
  • Publication date 1993
  • ISBN 10  0943158931
  • ISBN 13  9780943158938
  • Binding Paperback
  • Rating 3 avg rating • ( 2 ratings by Goodreads )

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COMMENTS

  1. Writing Psychological Reports: A Guide for Clinicians

    Learn more Follow the author Greg J. Wolber Writing Psychological Reports: A Guide for Clinicians Paperback - July 1, 2002 by Wolber (Author), Greg J. (Author) 4.5 25 ratings See all formats and editions

  2. Writing psychological reports: A guide for clinicians, 2nd ed

    This Second Edition of Writing Psychological Reports: A Guide for Clinicians offers several changes from the First Edition. A short section concerning the Notification of Purpose and Limits of Confidentiality has been added as well as a breakdown of the Background Information section into subsections.

  3. ""Writing Psychological Reports: A Guide for Clinicians ...

    "Writing Psychological Reports: A Guide for Clinicians" - Text by Greg Wolber and William Carne Neil Kenney, Nova Southeastern University Integrated report writing continues to develop as an essential dimension of training and competence.

  4. Writing psychological reports : a guide for clinicians

    Writing psychological reports : a guide for clinicians by Wolber, Greg J., 1948-Publication date 1993 Topics Report writing, Psychodiagnostics, Writing, Clinical psychology -- Authorship, Psychology, Clinical, Psychologie clinique -- Art d'écrire, Rapports -- Rédaction, Rapports -- Redaction, Psychologie clinique -- Art d'ecrire

  5. Writing Psychological Reports : A Guide for Clinicians

    Writing Psychological Reports: A Guide for Clinicians - Greg J. Wolber, William F. Carne - Google Books A refreshingly matter-of-fact guide. Provides a model for organizing psychological...

  6. How to write more useful assessment reports

    Pade, Wright and other clinicians provide more guidance on how to take your reports to the next level. Verify that your report relies on solid data. Before the report writing even begins, make sure that the tests you will be citing in the report are backed by the latest research and were used appropriately, Wright says.

  7. Writing Psychological Reports : A Guide for Clinicians

    Writing Psychological Reports: A Guide for Clinicians Greg J. Wolber, William F. Carne Professional Resource Press, 2002 - Language Arts & Disciplines - 143 pages This new second edition brings...

  8. Writing psychological reports: A guide for clinicians.

    Citation Wolber, G. J., & Carne, W. F. (1993). Writing psychological reports: A guide for clinicians. Professional Resource Press/Professional Resource Exchange. Abstract The purpose of this book is to present a structured format for writing a psychological report.

  9. Writing a Psychological Report Using Evidence-Based Psychological

    Principles on psychological report writing derived from seminal papers in the field of psychological assessment were adapted and used as an organizing tool to create a template on how to write all varieties of psychological reports that incorporate evidence-based assessment methods.

  10. Psychological Reports: A Guide to Report Writing in ...

    Psychological Reports: A Guide to Report Writing in Professional Psychology, 3rd Edition ISBN: 978--471-16887-4 Provides a systematic approach to writing psychological reports foroptimal clarity, thoroughness, and impact A clinical report should have all the clarity and precision of amilitary dispatch.

  11. A Quick Guide to Clinical Writing for Psychologists

    A Quick Guide to Clinical Writing for Psychologists by Annie Varvaryan, PsyD | Mar 6, 2017 | Lifehacks, Tips & Advice Are there any tasks you do as a trainee, intern or psychologist that you did not expect to do before choosing a career in psychology? One task that may come to mind is writing.

  12. Writing Psychological Reports: A Guide for Clinicians Paperback

    A fairly introductory text that proposes a common model of psychological report writing for most health related purposes. Don't feel it goes beyond the "essentials" series or most general psychology texts, and little coverage of forensic or neuropsychology settings. Read more.

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  14. Psychological reports: A guide to report writing in professional

    Since the quality of clinical reports can have a direct bearing on the quality of care a client receives—especially in an age of managed care—it is essential that psychologists arm themselves with a systematic approach to creating reports that in structure, contents, and style have the utmost clarity, thoroughness, and utility. This book provides them wit such an approach. The book begins ...

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    Corpus ID: 68374986; Writing Psychological Reports: A Guide for Clinicians @inproceedings{Wolber1993WritingPR, title={Writing Psychological Reports: A Guide for Clinicians}, author={Gregory J. Wolber and William F Carne}, year={1993} }

  16. Writing Psychological Reports: A Guide for Clinicians (Secon

    Writing Psychological Reports: A Guide for Clinicians (Second Edition) by Greg J. Wolber & William F. Carne Share | Writing Psychological Reports: A Guide for Clinicians (Second Edition) Write a Review Your Price: $24.95 Retail Price: $29.95 Your Savings: $5.00 (17%) Order Code : WPR2 Availability: In Stock Quantity Add to Cart DESCRIPTION

  17. Writing Psychological Reports: A Guide for Clinicians

    Writing Psychological Reports: A Guide for Clinicians by Wolber, Greg J.; Carne, William F. - ISBN 10: 0943158931 - ISBN 13: 9780943158938 - Professional Resource Exchange, Incorporated - 1993 - Softcover

  18. Writing Psychological Reports: A Guide for Clinicians

    Buy Writing Psychological Reports: A Guide for Clinicians by Greg J Wolber, William F Carne online at Alibris. We have new and used copies available, in 2 editions - starting at $1.45. ... All Editions of Writing Psychological Reports: A Guide for Clinicians . 2002, Hardcover. ISBN-13: 9781568870762. 1993, Trade paperback. ISBN-13: 9780943158938.

  19. How to Compose a Report in Clinical Psychology

    2. Procedure and techniques used. Make a list of the techniques, tests, questionnaires, etc. used to obtain the information. In addition, it's necessary to indicate the raw data obtained in the tests (especially if the report is going to be remitted to another psychologist). Psychological evaluation is a scientific procedure.

  20. Writing Psychological Reports: A Guide for Clinicians

    This guide for students, interns, and clinicians describes how to write a general psychological report. A single report format is presented with an explanation of the content for each section of the format. A sample confidential psychological evaluation is included in the appendix.

  21. Writing Psychological Reports: A Guide for Clinicians Paperback

    Find the best prices on Writing Psychological Reports: A Guide for Clinicians by Greg J. Wolber; William F. Carne (Joint Author) at BIBLIO | Paperback | 1993 | Professional Resource Press | 9780943158938

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