Abstract
Great variability exists in written forensic psychiatry reports. A template is offered for quick preparation of such reports. The template includes the standard elements of competency and criminal responsibility reports. The method makes use of currently available computer technology.
Forensic psychiatry reports that are helpful to courts are clearly written and orderly. Helpful reports give the court unambiguous conclusions with which it can either agree or disagree. Reports that require clarification for the court are less helpful than reports that require no clarification.
The Private Practice Committee of AAPL presents a course every two to three years at the annual meeting. The course teaches participants how to do the work of a forensic psychiatrist and how to establish a practice. It is one of the many educational programs1 and publications that establish the standards for forensic psychiatry reports.
The standards for a helpful forensic psychiatry report are as follows:
State who requested the evaluation.
List the questions to be answered in the report.
List the sources of the data on which the evaluation is based.
Document the information (and warnings) given to the examinee at the beginning of the examination.
Document, source by source, the relevant information gathered.
Document the examiner's (objective) observations of the examinee.
Discuss the examiner's reasoning in reaching his or her conclusions.
List the examiner's unambiguous answers to the questions to be answered in the report (second listed item).
I offer these four points to make reports clear and easy to read:
Limit sentences to 24 words or fewer.
Limit paragraphs to 10 sentences or fewer.
Limit sections to 10 paragraphs or fewer.
Use a title for each section.
The Template
The Appendix illustrates a template for a written report on competency to stand trial and criminal responsibility. It is offered as a public domain document, which means that everyone is free to copy it, modify it, and use it in any way. It is offered in this way to standardize the elements included and excluded in a report on competency and criminal responsibility.
The AAPL Private Practice Committee produced a similar public domain document in 1997. That document was a model service agreement and is published in Establishing a Forensic Psychiatric Practice.2
Both the report template and the service agreement template are available from the author in Microsoft Word document format.
The report template is designed to expedite the process of creating reports. Reports are commonly prepared by dictating or typing, with standard paragraphs inserted at appropriate places. The template provides the whole report, for both competency and criminal responsibility, with both the dictated and inserted paragraphs already in place. The user need only fill in the blanks.
The template's word processing format allows all parts of it to be modified or deleted. Additions can be inserted anywhere. It is set up as a default template. Only the parts that require changes need be modified. Parts that need no modification can be skipped.
The word processing format allows the user to modify the template to create a document that suits his or her personal style. The user can create a personalized template for court-appointed cases, a different one for private cases, and so forth.
Moving the Cursor Efficiently
As mentioned earlier, this template streamlines the mechanics of writing reports. By entering Ctrl + j, the cursor goes to the next cursor stop for text modification, eliminating the time otherwise used to move the cursor manually to the next text modification spot. Each cursor stop is designated by an ampersand (&), which is erased as the user moves to the next cursor stop. At each ampersand, the writer modifies the text, deletes the text, or leaves the text unchanged in its default form. If the text is left in its default form, then nothing further is done at that cursor stop. If the text is modified, then the writer types or dictates the new text. If the text is deleted, it is highlighted and deleted or is deleted by holding down the delete key.
Some of the cursor stops are designed for easy modification. For example, “He is & able to concentrate” can be easily modified to, “He is unable to concentrate.” Then, as much embellishment as desired can be added, or the text can be left as is.
Other cursor stops require modification. An example is the cursor stop that details the findings that support a conclusion of incompetence to stand trial.
Using Macro Commands
A macro command must be programmed so that the computer will respond to the Ctrl + j command. The macro reduces a command of several keystrokes to one of a single keystroke. The ampersand macro command is easily set up with these steps:
Click on Tools
Click Macro
Click Record New Macro
Click on Keyboard icon
In the “Press new shortcut key” dialogue box, type Ctrl + j (hold “Control” key while typing “j”)
Click “Assign”
Click “Close”
(New small dialog box appears)
Type on keyboard: Ctrl + f
In the “Find What” box, tap the ampersand (shift + 7)
On keyboard: Enter
On keyboard: Escape
On keyboard: Backspace
In the small dialogue box, click the small blue square.
Now, anytime Ctrl + j is typed on the keyboard, the cursor will go to the next ampersand and erase it. The cursor will then be ready for text to be typed, dictated, or deleted at the spot where the ampersand was. If no text modification is needed, then Ctrl + j is typed again to move the cursor to the next ampersand. If more than one cursor stop is left in its default state, then the Ctrl key can be held down while the j key is tapped repeatedly.
The mouse can be used to access the macro command. However, so many mouse clicks are needed that it is not worth doing. Therefore, this system works efficiently only if the keyboard command, Ctrl + j, is used to get to the next ampersand.
Mechanism for Taking Notes
There are many ways to take notes during a forensic examination. I find the most efficient way is to type my notes directly into the template on a laptop computer. For example, after asking the examinee if he has criminal charges against him, I type his answer at the ampersand. His answer can be quoted or paraphrased. After his answer is entered, I type Ctrl + j, and ask the examinee the next question: how can you plead to these charges? After I enter his answer at that cursor stop, I type Ctrl + j, and so forth. Later, at my desk, I correct typographical errors and rephrase my entries as necessary, either by typing or dictating. Also, I can print a rough draft, mark it with a pen, and give it to an assistant for completion.
This template lends itself to the efficiency of using voice recognition software to dictate at each cursor stop. The keyboard can be used to get to the next ampersand. Then the dictation goes directly into the template at the right spot. When that spot is completed, then Ctrl + j moves the cursor to the next cursor stop where dictation is entered. With this method, the user can personalize the template to suit his or her dictation style.
Appendix: Forensic Psychiatry Report Template
Letterhead &
Date: &
& Insanity or & Competency Evaluation
Re: &
Dear &:
At your request, I performed a psychiatric evaluation of the defendant, &, at & my office on &. My examination of him began at & pm and ended at & pm. The purpose of this evaluation was to determine his competence to stand trial and his criminal responsibility (insanity) regarding his current criminal charges.
Prior to my examination of him, I reviewed the several documents & you sent. They consisted of &.
At the beginning of my examination of the defendant, I explained the purpose of the examination, and that my findings would not be confidential. I explained that my findings would be released to & you, and in any hearings that might occur. I explained that I would not be treating the defendant and that I am not his treating physician. I explained that the usual doctor-patient confidentiality does not exist in this examination. The defendant did sign a consent allowing me to examine him, release my findings to & you, and record the examination. The examination was videotaped.
The following are my findings and conclusions regarding today's psychiatric evaluation of this defendant.
Identifying Data
The defendant is a & year old, & white, & married father of& 3.
(Erase from here for sanity report.)
Data Regarding Competence to Stand Trial
The following is the information given to me by the defendant during this examination in response to the questions I asked him.
The defendant does have criminal charges pending against him. The charges against him are, &. The pleadings available to the defendant include, &. If the defendant is found guilty, the maximum sentence he faces is, &. The minimum sentence he faces is, &. The other sentences that the defendant might get include, &. If the defendant is found guilty, the sentence he is most likely to get is, &.
The defendant & does have an attorney. The attorney is & a pubic defender. The role of the defendant's attorney is, &. The attorney on the other side of the defendant's case is called, &. The role of the prosecuting attorney is &.
The role of the judge is, &. The role of the jury is, &. What happens in a trial is, &. The defendant's turn to talk during a trial is, &.
If, during his trial, the judge overrules an objection, that means, &. If the judge sustains an objection, that means, &. If a witness is testifying against a defendant, and the defendant sees that the witness is lying, the defendant should, &.
The defendant is & familiar with plea bargaining. Plea bargaining is, &.
The defendant's plan for his legal strategy regarding the charges against him is, &.
The events leading to the charges presently against the defendant were, & (Fill in next section, then return here.) &. If the defendant is asked on the witness stand &, then he would testify, &.
(Erase to here for sanity report.)
(Erase from here for comp report.)
History of Incident in Question
The following is the information given by the defendant regarding the incident in question:
&
(Erase to here for comp report.)
Present Symptoms
The following is further information given by the defendant in today's examination:
The defendant sleeps & well. His appetite is & good. He is & able to concentrate. He is & able to sit still. His memory is & good. He & denies loss of interest in his usual activities, including his self care.
The defendant & denies feeling depressed at this point. He & denies any history of suicidal thoughts. He & denies history of suicide attempts.
With regard to symptoms of psychosis, the defendant & denies hearing things that are not there. He & denies seeing things that are not there. He & denies that others follow him or spy on him. He & denies that others listen in on his thoughts. He & denies that the television watches him.
The defendant & denies lack of energy. He & denies feeling worthless. He & denies feeling slowed down.
With regard to symptoms of mania, the defendant & denies feeling extremely happy for no reason (inappropriate euphoria). He & denies feeling the need for only 2–3 hours of sleep per night (manic sleep pattern). He & denies talking so fast that others tell him to slow down (pressured speech). He & denies spending a lot of money for things he doesn't really need (manic spending). He & denies making big plans that are unrealistic (grandiosity).
Physical Health History
The following is the information given by the defendant regarding his physical health and physical health history.
The defendant is & physically healthy. & He denies any history of significant illness such as & cancer, & heart disease, & diabetes, or & epilepsy.
Medications
The following is the information given by the defendant regarding his medications.
The psychiatric medications the defendant presently takes are &.
The nonpsychiatric medications the defendant presently takes are &.
Psychiatric History
The following is the information given by the defendant regarding his psychiatric history.
&
Education and Employment History
The following is the information given by the defendant regarding his employment history.
The defendant graduated from high school at age & 18. He had no schooling after that. His first job after high school was &.
Family History
The following is the information given the by defendant regarding his family history.
The defendant lives & alone. He &has never been married. He has & 3 children.
Religion does & play an important part in the defendant's life. It is a support to him and not an area of conflict. &
Drug and Alcohol History
The following is the information given to me by the defendant regarding his history of use of drugs and alcohol.
The defendant & denies the use of alcohol. He & denies the use of street drugs. He has & never been treated for alcoholism or substance abuse.
Legal History
The following is the information given to me by the defendant regarding his legal history.
The defendant & denies any history of criminal charges other than the above. He & denies any history of involvement in any lawsuits. He & denies any other involvements in the legal system.
Mental Status Examination
The following are the answers given by the defendant today to the questions I asked him in a standard mental status examination.
Today is, &. I am, &. This place is, &. The Presidents in reverse order are, Bush, Clinton, Bush, &. Serially subtracting $7.00 from $100, 93, 86, 79, 72, 65 &.
If the defendant were walking down the street, and found a letter lying next to a mailbox, he would, &. If the defendant were in a theater and saw the curtains on fire, he would, &. If someone said to the defendant that the grass is always greener on the other side of the fence, that person would be trying to say, &. If someone said, don't cry over spilled milk, that would mean, &.
The defendant is & able to name 3 objects after 5 minutes. (A normal person can name 3 objects after 5 minutes.) The defendant is able to repeat & 7 digits forward and & 4 digits backward. (A normal person can repeat 7 digits forward and 4 digits backward.) With regard to calculations, 5 + 6 =, & 11; 5 × 6 =, & 30; 5 − 6 =, & −1.
Five large cities are, &. Choosing between & and &, the one that is further & east is &. The distance from & to & is &.
The reason that people pay taxes is &. The reason that games have rules is &.
The difference between a bird and an airplane is &. Their similarity is &. The difference between a bush and a tree is &. Their similarity is &. The difference between an apple and an orange is &. Their similarity is &. The number of legs on a horse is, & 4. The shape of the (rectangular) picture frame on the wall is, & rectangle. The shape of the (round) clock on the wall is, & round. The colors of the American flag are, & red, white and blue.
Observations
The following are my observations regarding this defendant.
The defendant is & alert, oriented, appropriate, calm, cooperative, likable, and friendly. The defendant related to me in a & normal fashion during today's examination. The defendant is & free of psychosis, depression, mania, and confusion. He appears & able to think clearly. At this point the defendant appears to be psychiatrically & normal.
The defendant is & able to carry on a normal conversation and answer questions appropriately. The defendant's behavior in today's examination was & calm and cooperative. The defendant demonstrates during today's examination that his motivation is & self-serving and not self-defeating.
Discussion
The following are my thoughts regarding this case.
(Erase from here for sanity report. This section regards competence.)
Indiana Code 35-36-3-1 states that a defendant is incompetent to stand trial if the defendant lacks the ability to understand the proceedings and assist in the preparation of a defense.
&
(Erase to here for sanity report.)
(Erase from here for comp report. This section regards sanity.)
Indiana Code Section 35-41-3-6 states that a person is not responsible for having engaged in prohibited conduct if, as a result of mental disease or defect, he was unable to appreciate the wrongfulness of the conduct at the time of the offense. As used in the section, mental disease or defect means a severely abnormal mental condition that grossly and demonstrably impairs a person's perception, but the term does not include an abnormality manifested only by repeated unlawful or antisocial conduct.
&
(Erase to here for comp report.)
(Erase from here for sanity report.)
McGarry Criteria
The following are the McGarry criteria for competence to stand trial, and my determination of whether this defendant fulfills each criterion. My determination is based upon my judgment regarding the information gathered during today's examination. (The McGarry criteria are taken from McGarry Al, Curan WJ, Lipsett PH, et al: Competency to Stand Trial and Mental Illness. Rockville, MD: NIMH, 1973.)
Does the defendant have the ability to appraise the legal defenses available to him? & Yes.
What is the level of the defendant's unmanageable behavior? & Low.
What is the quality of the anticipated manner in which the defendant will relate to his attorney? & Cooperative.
Does the defendant have the ability to plan a legal strategy? & Yes.
Does the defendant have the ability to appraise the roles of the various participants in the courtroom proceedings? & Yes.
Does the defendant understand the procedures of the court? & Yes.
Does the defendant have an appreciation of the charges against him? & Yes.
Does the defendant have an appreciation of the range and nature of the possible penalties he faces? & Yes.
Does the defendant have the ability to appraise the likely outcome of the charges against him? & Yes.
Does the defendant have the capacity to disclose to his attorney available pertinent facts surrounding the offense? & Yes.
Does the defendant have the capacity to challenge prosecution witnesses realistically? & Yes.
Does the defendant have the capacity to testify relevantly? & Yes.
Does the defendant manifest self-serving motivation or self-defeating motivation? Self-serving & motivation.
(Erase to here for sanity report.)
Conclusions
The following are my conclusions regarding this defendant, to a reasonable degree of medical certainty, based upon the above history and findings.
(Erase from here for sanity report.)
-
It is my judgment that this defendant presently & has the ability to understand the proceedings against him. He is & adequately able to describe the charges against him, & the possible sentence he faces, & the roles of the various people in the courtroom, & the process of plea bargaining, and & the part he plays in his trial.
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It is my judgment that this defendant presently & has the ability to assist in the preparation of his defense regarding the criminal action against him. He is free of & psychosis, & depression, & mania, and & confusion. He is & able to think clearly. He is & able to answer questions appropriately. He is & able to carry on a normal conversation. He is & able to relate to me appropriately in today's examination. He is & able to put his thoughts into words.
-
Based upon above 2 conclusions, it is my judgment that this defendant presently is & medically competent to stand trial.
(Erase to here for sanity report.)
(Erase from here for comp report.)
-
It is my judgment that this defendant was & able to appreciate the wrongfulness of his conduct at the time of the offense. The findings that support this conclusion are &
(Erase to here for comp report.)
If I can address any further issues for you, or clarify any questions, I will be glad to do so in writing or on the record. I thank you for the opportunity to examine this interesting case and to address these interesting questions. I do give you my consent to release this report to any appropriate party.
Respectfully submitted,
Steven H. Berger, MD
Board Certified in General Psychiatry and Forensic Psychiatry
- American Academy of Psychiatry and the Law
