Writing and Reading Mental Health Records

Issues and Analysis in Professional Writing and Scientific Rhetoric

J. Frederick Reynolds, David C. Mair, Pamela C. Fischer

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136687471
• Edition: 2
• Topic: Languages & Linguistics
• Subtopic: Communication Studies
• Index: Languages & Linguistics

This revised and updated second edition is a rhetorical analysis of written communication in the mental health community. As such, it contributes to the growing body of research being done in rhetoric and composition studies on the nature of writing and reading in highly specialized professional discourse communities. Many compelling questions answered in this volume include: * What "ideological biases" are reflected in the language the nurse/rhetorician uses to talk to and talk about the patient?
* How does language figure into the process of constructing meaning in this context?
* What social interactions -- with the patient, with other nurses, with physicians -- influence the nurse's attempt to construct meaning in this context?
* How do the readers of assessment construct their own meanings of the assessment? Based on an ongoing collaboration between composition studies specialists and mental health practitioners, this book presents research of value not only to writing scholars and teachers, but also to professional clinicians, their teachers, and those who read mental health records in order to make critically important decisions. It can also be valuable as a model for other scholars to follow when conducting similar long-range studies of other writing-intensive professions.

Chapter 1
A Review of the Literature on Mental Health Records

We spend countless hours teaching graduate psychology students and psychiatric residents how to interview, how to administer and interpret tests, and how to do therapy. All of these enterprises end up on paper.... And yet there is little or no training given on how to write.

—Jack T. Huber Report Writing in Psychology and Psychiatry 1961

Introduction and Overview: From the 1940s to the 1990s

Problems associated with writing and reading mental health records have been a subject of concern among both scholars and clinicians since the 1940s. In this chapter, we review in detail what we believe to be the key contributions to the professional literature on mental health records to date. We think it might be useful to preface our review by calling special attention to several themes that consistently recur throughout this body of literature:

Theme 1: There has been relatively little systematic study of mental health records, despite the critical role they play in patient care and management.

Theme 2: Mental health practitioners receive surprisingly little training in how to write and read a record, given the amount of time they tend to spend doing both.

Theme 3: Communication between professionals in the mental health community is especially complicated as a result of its unusually wide variety of writer/reader backgrounds, care-delivery settings, and documentation standards.

The following two studies, for example, were published more than four decades apart, and yet they focus on the same basic findings:

In 1946, Taylor and Teicher¹ reported in the Journal of Clinical Psychology that "clinical psychology ... appears to have given little systematic study to the manner in which test findings are organized and formulated to provide necessary records and to render data easily and fully understood by professional associates" (p. 323). They expressed concern about the fact that "the many well-written, well thought-out psychological reports found in current practice appear to stem from individual institution or individual study of the problem of recording, rather than from a commonly accepted system" (p. 323). "It is conceivable," they argued, "that the psychiatrist or social worker who relies upon the work of the clinical psychologist may frequently be confused or frustrated because methods of reporting data are so varied and lacking in central philosophy and direction" (pp. 323-324). "Apart from [these] technical considerations," they further noted, "one's manner of relating to others and the way he feels and thinks will creep into his writing" (p. 332).

In 1989, Reynolds and Mair reported in the Journal of Technical Writing and Communication that "documentation in the mental health professions has received little study despite the fact that mental health records can be as crucial to a patient's well-being as medical records" (1989a, p. 245). They expressed concern that documentation standards varied widely, that they had found "only one point common among most mental health professionals working in the field" [their reliance on DSM nomenclature] (p. 246), and that "the factors that appear to have the most influence on document content are not immediately pertinent to patient well-being" (p. 253). "The communication situation is complicated," they observed, "by the wide variety of educational backgrounds of the various report writers and readers" who receive "little or no formal instruction in writing" and who instead "learn report writing during clinical practice, thereby learning from models—good and bad—and perpetuating the idiosyncrasies of reports at their host institutions" (p. 246).

The fact that these two studies, as well as most of those published during the 40-plus years in between them, so closely mirror one another raises some interesting preliminary questions. Why, for example, does nearly 50 years of professional work investigating the same basic research problem keep reaching the same basic conclusions? Why are key recommendations and conclusions (e.g., that mental health practioners need more training in writing and reading records) not acted upon? Is there widespread belief (and, if so, why?) that the difficulties associated with writing and reading mental health records are simply inherent and unsolvable? Are researchers addressing the problem of mental health records from so many different disciplinary perspectives that they are largely unaware of pertinent research published previously by researchers from other fields? We think the latter to be unlikely because at least some of the literature that follows crosses disciplinary lines, and either quotes from or makes reference to the body of work that preceded it. In any event, we hope that the compilation and review that follows will prove especially useful to practitioners who must write and read these records daily, and to those who study the problem of mental health records in the future.

Major Contributions from the 1950s and 1960s

Sargent (1951) noted that written communication between psychologists and psychiatrists was "an important interprofessional problem," and that "the question of what a test report should communicate, and in what fashion, is a much discussed subject among both the writers and the consumers of test interpretations, but has not been answered to the full satisfaction of either" (p. 175). In order to demonstrate and compare different methods of reporting, Sargent presented four reports composed by the same psychologist about a single patient referred for acute anxiety and incipient schizophrenia. The reports, she concluded, differed in "purpose, vantage point, and logical orientation" (p. 184), and none "actually described the individual in a way which would make him recognizable among others except on close examination" (p. 185). Sargent concluded that the latter raised "a fundamental issue regarding the value of test findings" (p. 185), as well as the questions "What is the purpose of a psychological test report? Do we who write them share the purposes of those who read them? If not, who is to educate whom to their fullest usefulness?" (p. 186). Sargent argued for "greater flexibility and caution" (p. 186).

Foster (1951) reported that "most students in clinical psychology are poorly trained in report writing techniques." The cause, he felt, was that "their instructors, who, being psychologists themselves, accept technical test terminology as proper," and typically fail to focus on teaching their students how to provide information "in language which is meaningful in terms of the patient" (p. 195). Foster offered four simplified guidelines for better reports.

Lodge (1953) similarly offered beginning psychological report writers "a step-by-step guide [which they might use] until they have had sufficient opportunity to develop their own methods and standards for reporting" (p. 400).

Garfield, Heine, and Leventhal (1954) wrote of psychological report writing that "comparatively little discussion has appeared in the literature concerning this important activity," and that "critical evaluations of current report writing have been negligible" (p. 281). They distributed a 1-month sample of reports to all professional staff members in a mental hygiene clinic for their critical evaluation. Sixteen reports were analyzed and evaluated by 9 psychologists, 13 psychiatrists, and 11 psychiatric social workers. Noticeable differences between the three professional disciplines were observed. Psychiatrists, the researchers found, tended to be most critical of the reports, whereas social workers were least critical. The most frequent criticisms were that the reports were vague, unclear, speculative, inconsistent, and filled with technical jargon and clichés.

Cuadra and Albaugh (1956) prefaced their work by noting that "relatively little research has appeared which bears on the adequacy of psychological reporting per se," and that "no published research has dealt directly with the basic problem of communication" (p. 109). They presented four "representative, although not random[ly selected]" psychological reports to 56 "judges representing six professional groups" for their analysis and evaluation, and used questionnaires of both writers and readers to measure the degree of correspondence between the writers' intentions and the judges' interpretations. Results "indicated that communication was scarcely better than 50 per cent," and that "the greatest breakdown in communication occurred when the judges did not agree with the authors as to what was being emphasized" (p. 113). Caudra and Albaugh concluded that "there were relatively few gross errors in interpretation," and that "most of the breakdown involved problems in the specification of degree," but noted that "questions of degree are often of paramount clinical importance" (pp. 113-114). They recommended that report writers be taught to be "extremely explicit" and "direct" about their "points of emphasis" and "statements of degree" (p. 114).

Tallent and Reiss (1959a, 1959b) published a series of articles based on an extensive survey that "deliberately attempted to seek out the negative features of clinical reports with a view to publicize them so that they might be reduced in future writing." Printed research forms were mailed to 741 psychiatrists, 433 psychiatric social workers, and 393 psychologists, all of whom were employees of the Veterans Administration. Return rates were 81.2% for the psychiatrists, 97.2% for the social workers, and 97.7% for the psychologists. Respondents' criticisms were grouped as follows: problems of content, problems of interpretation, problems of attitude, and problems of communication. In analyzing their data, Tallent and Reiss reported finding "apparently meaningful patterns of criticism" showing "variations in preferences" (p. 446). Psychiatrists, for example, complained of too little raw data in the reports, whereas psychologists saw the reports as containing too much raw data. Psychiatrists wanted more direct reporting of patient behavior, whereas psychologists preferred more interpretation. Both complained about the absence of clear statements of purpose, and about excessive length, wordiness, and "deficiencies of terminology" (p. 445).

After noting that "amazingly little systematic attention has been paid to the writing of the psychological report," Bellak (1959) argued that the problems of communication in the mental health community "are variously inherent in the tools, concepts, and organization of the report itself." Furthermore, he warned, "Aside from the mechanics of the relationship, psychologists and psychiatrists are, of course, people. Their own emotions, value systems, apperceptive distortions, and their semantic problems enter into this area of communication" (pp. 76-77).

Feifel (1959) insisted that many of the "semantic obstacles" that interfere with written communication between psychiatrists and psychologists "stem from theoretical confusion" (p. 77), and suggested that communication might be improved if more research focused on clarifying the "frames of reference" and "working assumptions" from which the various practitioners' communications proceed.

Similarly, Klopfer (1959) described "the psychological report as a problem in interdisciplinary communication" (p. 86), and called for heightened attention to purpose, organization, and language. Klopfer advocated that writers determine their purpose on the basis of how their reader(s) would use their report; that they organize their work according to personality areas; and that technical terminology be "assiduously avoided." Further, Klopfer noted, "If the psychological report is to be utilized for a variety of purposes and is addressed to semi-professional and non-professional referrents as well as professional ones, it may be necessary to prepare several different reports. A report designed to serve too many different purposes [and, by implication, too many different readers]," he warned, "may serve none adequately" (p. 87). Klopfer recommended oral reporting as "the method of choice when communicating to school teachers, social workers, nurses, and other individuals whose professional training includes psychological matters only tangentially" (p. 87).

In 1964, supported in part by a grant from the National Institute of Mental Health, Lacey and Ross sought to replicate Tallent and Reiss' research, which had been conducted in Veterans Administration installations, in child guidance clinics. Their results suggested major differences between points of view in the two types of mental health care settings. Lacey and Ross attributed these differences to "structure, function, and interprofessional relations," and concluded that "a psychologist trained in a Veterans Administration setting will not readily find a child guidance clinic a congenial environment in which to work" unless he or she has had "specialized preparation not only in how to test or treat children but also in how to write acceptable psychological reports" (pp. 525-526).

Lacks, Horton, and Owen (1969) reported on their attempt to develop and subsequently test over a 6-month period a simple, standardized form for presenting psychological test findings. "In spite of the continued dissatisfaction with psychological reports throughout the years," they noted, "relatively little attempt has been made to actually change the form of these reports" (p. 386). They concluded that an outline form could be valuable in speeding up the writing of reports and also in presenting findings in a clearer, more concise fashion than the standard narrative form. They felt that the outline form would be particularly suitable in a setting that emphasized prompt evaluation over reporting extensive personality dynamics. The researchers also noted those studies that had preceded their own, commenting on the fact that "there seemed to be no consensus reached in these studies except that various professional groups in each setting differed on what they thought was desirable in a psychological report" (p. 383).

Key Developments During the 1970s

The Problem-Oriented Record Movement/Debate

Grant and Maletzky (1972) were among the first researchers to note that well-kept patient records served multiple purposes in the mental health community. Records, they reminded their readers, had not only clinical but also research, teaching, and legal implications. Many patient records, they warned, failed to serve these purposes, because of "poorly operationalized constructs" as well as "purely mechanical reasons."

Given the multiple purposes that mental health records increasingly served, Katz and Woolley (1975) concluded that problem-oriented records (POR), as described and popularized by Weed (1968, 1969), offered promising improvements. "Problem-oriented records," they noted, "provide a potentially useful means of reorganizing existing patient records so that relevant clinical information is collected, displayed, and more easily dealt with in a logical way" (p. 123). The POR system (which advocated, essentially, that a patient record include an initial data base, a problem list, progress notes, and a discharge summary, and that the problem list provide the structural framework for all of the documents in the record) was seen by Katz and Woolley as having certain key advantages. First, problems are "functionally defined in behavioral rather than abstract, mentalistic, or diagnostic terms" (p. 123). Second, progress notes are "indexed by date, number, and title . . . and not fragmented by professional discipline" (p. 121). Third, discharge summaries "can aid in ongoing program evaluation, and be of considerable assistance to those who may be involved in the care of the patient elsewhere or on another occasion" (pp. 122-123). The basic principles of the POR format, Katz and Woolley contended, could be generalized to a variety of settings and treatment approaches.

Sturm (1987) reported that throughout the 1970s and early 1980s Weed's POR system was subsequently studied widely and debated in the mental health community. Sturm cited Biagi's work in social work, Haber's in psychiatric nursing, Miller's in clinical psychology, and Ryback's in psychiatry. "There have been many criticisms relevant to psychology of the value of the Weed system" (p. 157), Sturm noted. Of special significance to those interested in further exploring the POR movement of the 1970 is a study by Webb et al. (1980). It investigated the reliability of the POR system by examining the degree of interrater agreement among four therapists' ratings of the nature of the problem presented, and the severity of that problem, for 32 outpatients. Results indicated that the POR system was reliable for recording patients' problems on int...

Table of contents

• Cover
• Title
• Copyright
• Contents
• A Rhetorician's Foreword
• A Clinician's Foreword
• Preface to the Second Edition
• Introduction: The Growing Importance of Mental Health Records
• Chapter 1 A Review of the Literature on Mental Health Records
• Chapter 2 A Descriptive Taxonomy of Mental Health Records
• Chapter 3 Writer/Reader Biases and Mental Health Records
• Chapter 4 More on the DSM: The Language System of Mental Health Records
• Chapter 5 Clinicians' Thoughts on Mental Health Records: A Pilot Survey
• Chapter 6 Improving Mental Health Records: Instructional Strategies and Research Priorities
• Chapter 7 New Developments: 1992 to 1994
• Postscript
• References and Bibliography
• Index
• About the Authors
• About the Contributors