The Written Report in Consultation–Liaison Psychiatry: A Proposed Schema

Abstract

Objective: The consultation–liaison psychiatry (CLP) written report serves several crucial functions; it therefore needs to be presented in a meaningful format to its readers. Surprisingly little has been written about its optimal nature. Our aim is to offer a schema which promotes effective communication. Methods: We have reviewed pertinent literature, consulted with CLP colleagues and convened a focus group that a number of them attended. Results: The core functions of the CLP report are to offer the referrer (and other relevant professionals) key comprehensible findings, recommendations for treatment and advice for follow up. Additional purposes are educational, archival and medico-legal. Our schema contains eight sections: Who is the patient? Why you referred the patient to us at this particular time? What did we find? Who are the patient's family and other supports? How do we understand these findings? What do we recommend regarding management? What further clinical developments have ensued? and What do we recommend regarding psychosocial follow-up? We provide guidelines concerning the content of each section and illustrate the use of the schema with two clinical cases. Conclusions: The functions of the CLP report are not satisfied through conventional psychiatric-history note taking. Our related yet different framework is inclined to be a more effective means to convey necessary clinical data and treatment recommendations.