A Quick Guide to Clinical Writing for Psychologists

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:

1. 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.
2. Purdue Online Writing Lab
   Additional resources on APA formatting are available on the Purdue Online Writing Lab (OWL) website.
3. 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.
4. 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.