Formulation guide

Rapid clinical formulation guide

Explain this person’s presentation now, using selected evidence and revisable hypotheses, then identify the implications for assessment and care.

Guide moduleClinically reviewed

Explain this person’s presentation now, using selected evidence and revisable hypotheses, then identify the implications for assessment and care. History, diagnosis, a 5P matrix and a treatment list are not interchangeable with explanatory synthesis. ^S01^S02

A practical clinical-note sequence

This is an editorial aid, not a mandatory assessment format or validated score.

1. Present state: priority symptoms/problems, course, function, setting and immediate medical/safety concerns. 2. Diagnostic reasoning: working syndrome, important alternatives, evidence for/against and missing information. 3. Relevant context: selected biological, developmental, psychological, social, cultural and service factors, with their temporal roles. 4. Explanatory links: one or a few plausible sequences, supported by case evidence and challenged by alternatives. 5. Strengths and protection: elicited goals, agency and resources, including which supports are available now. 6. Risk and actions: current change, foreseeable difficulties, relevant access/opportunity, responsibility and reassessment. 7. Uncertainty and revision: contradictions and what information could alter the account.

“One or a few” is a readability recommendation, not a numerical clinical threshold.

Before choosing a psychological explanation

Consider acute illness, altered cognition, substances or medicines, pain, sleep disruption, communication/sensory needs, practical barriers, current danger and the service’s own behaviour. These are assessment prompts, not a universal investigation panel. ^S03^S08

A safe mechanism sentence

> In [observed context], [proposed process] may contribute to [response]. The immediate effect appears to be [function], while [later consequence] may maintain the difficulty. Evidence is [case evidence]. Alternatives are [alternatives]. [Missing or contradictory information] limits confidence.

This is a template, not patient content. Empty fields stay unknown/not assessed. A selected mechanism must not manufacture history, symptoms, risk, protections or preferences.

Caveats for this record

The sequence is an editorial aid, not a validated score or mandatory universal format.

Record status

Record type: Clinical guide module
Population: Adult-general psychiatry; specific evidence populations and jurisdiction qualifiers retained in body
Review: Clinically reviewed

Evidence

S01Formulation

Royal Australian and New Zealand College of Psychiatrists · HTML text. Learning outcomes, Stages 1–3.

An educational competency page, not a treatment guideline or evidence that a specific formulation template improves outcomes.

Link withheld: this source remains held and is cited as metadata only.

S02OCA and IOCA Formulation Guidelines

Royal Australian and New Zealand College of Psychiatrists · PDF text, pages 1–7; visual retrieval failed. PDF pp. 1–3, sections 1–6; p. 7 revision history.

Assessment convention, not a universal documentation rule. Historical examples include obsolete diagnostic axes and language that should not be copied. The 2025 update includes IOCA terminology, not demonstrated wholesale clinical revalidation.

S03Diagnosis and mental state

Royal Australian and New Zealand College of Psychiatrists · HTML text. Learning outcomes.

Competency source, not detailed diagnostic criteria or a medication guideline.

Link withheld: this source remains held and is cited as metadata only.

S08Comprehensive Care Standard

Australian Commission on Safety and Quality in Health Care · HTML text. Comprehensive assessment and care planning, Actions 5.10–5.14.

Organisation-level Australian standard, not a validated psychiatric formulation template.

Link withheld: this source remains held and is cited as metadata only.

Evidence references only. Each source's own limitations still apply.

Guide modules

Foundations, terminology and evidence limits Practical assessment-to-formulation workflow Risk formulation and management linkage Documentation templates and worked examples

How to use this

Record the case evidence yourself. Nothing here is a patient finding, and no factor becomes a cause because it appears in the formulation.

A practical clinical-note sequence

This is an editorial aid, not a mandatory assessment format or validated score.

“One or a few” is a readability recommendation, not a numerical clinical threshold.

A safe mechanism sentence

This is a template, not patient content. Empty fields stay unknown/not assessed. A selected mechanism must not manufacture history, symptoms, risk, protections or preferences.