By Dr. Brenda Gorman, CCC-SLP, Lingua Health Advisory Clinical Director
Dr. Brenda Gorman, CCC-SLP
What is “good” clinical writing ?
As part of an English assignment, an undergraduate student recently asked to interview me about clinical writing in speech-language pathology. She is also planning to major in Communication Sciences and Disorders.
At first, I thought it would be a fairly straightforward interview. Clinical writing is vastly different from the casual writing styles of texting, email, and blogging that we do every day. Strong clinical writing requires correct grammar and punctuation. Active voice is preferable to passive voice. The writer must also present information clearly and concisely to reduce wordiness.
Not that the story need be long, but it will take a long while to make it short.
- Henry David Thoreau
The more the student and I talked, the more I remembered to appreciate what a complicated and unique task clinical writing really is. She then asked if I could compare the clinical writing of “strong” graduate student writers with the writing of students who struggled.
As a supervisor, I have found that one common area of difficulty is with terminology. Clinicians should use proper clinical terminology that other professionals who read the report will understand. When writing clinical reports, therefore, students should review terminology that they learned in class. At the same time, the writer should define any jargon that the client or a family member would not understand.
Another area of difficulty that I have seen often is with objectivity. Clinicians should report what the client actually did, sticking to facts and data, rather than describe the client’s behaviors subjectively. For example, instead of writing that the client “seemed” tired, we might say that “The client closed his eyes and put his head on the desk during the assessment.” The client may have been tired, but his behavior may also have resulted from frustration or boredom. The clinician can only know for sure what she saw.
Then, there is a very common corpus of words and phrases that experienced clinicians use, such as:
“His parents/teacher reported…”
“According to his parents/teacher…”
“His parents/teacher expressed concerns that…”
“His parents/teacher expressed no concerns with…”
“The client demonstrated/displayed…”
“The client performed within normal limits for his age…”
“His score fell in the ____________ range”
“There is nothing to writing. All you do is sit down at a typewriter and bleed.”
I know that many students feel a great deal of frustration with all of the revisions their supervisors request that they make. Thank goodness for computers! Try not to take it personally. Their comments are fully intended to benefit you and your clients. Your documentation may become a legal document. Other professionals who read your reports will make judgments about you and your competence based on your writing. Someday, you will too.
Strong clinical writing skills will only develop with practice and guidance, so try to look at the red ink and remember that your supervisors are helping you become the best clinician possible. So keep your head up. It will get easier!