Example 1: SIGN 145-compliant ASD diagnostic report

Disclaimer: Educational example only

This diagnostic report is a fictional example created for educational and informational purposes only. It demonstrates what a comprehensive, SIGN 145-compliant adult autism assessment report should contain when conducted to Scottish clinical standards.

Important notes:

This is not a real person or genuine clinical report - all details, scores, and clinical observations are illustrative examples. Real assessments will vary - each individual's presentation, history, and support needs are unique. This example shows best practice standards - your actual assessment should meet these quality benchmarks, though format and specific content may differ between services. Use for awareness and advocacy - this example can help you understand what comprehensive autism assessment should include and advocate for appropriate standards of care. Not a substitute for professional assessment - this example cannot be used for self-diagnosis or in place of formal clinical evaluation. If your assessment does not meet these standards, you may wish to seek a second opinion or raise concerns through appropriate channels.

SIGN 145 core requirements - FULLY MET

✔️ Multidisciplinary Team assessment

Requirement: Assessment by appropriately qualified multidisciplinary team
Evidence: Five qualified professionals with clear registration numbers:

Lead Clinical Psychologist (HCPC: PYL12345)
Consultant Psychiatrist (GMC: 1234567)
Speech & Language Therapist (HCPC: SL12345)
Occupational Therapist (HCPC: OT12345)
Autism Specialist Practitioner (NMC: 12A3456E)

✔️ Comprehensive developmental history

Requirement: Detailed developmental history using validated tools
Evidence:

ADI-R administration with mother as informant
Background history covering early development, education, employment
Clear developmental timeline with specific examples
Family history included

✔️ Direct clinical observation

Requirement: ADOS-2 or equivalent structured observation
Evidence:

ADOS-2 Module 4 administered by qualified clinician
Clear scoring (Social Affect: 13, RRBs: 5, Total: 18)
Autism spectrum classification achieved
Integrated with overall assessment

✔️ Cognitive assessment

Requirement: Assessment of intellectual functioning
Evidence:

Full WAIS-IV battery (FSIQ: 108 - Average range)
Detailed cognitive profile showing strengths and weaknesses
Clear ruling out of intellectual disability
Integration with adaptive functioning

✔️ Adaptive functioning assessment

Requirement: Assessment of daily living and adaptive skills
Evidence:

Vineland-3 administration across all domains
Clear scoring showing socialisation difficulties (74 - Low)
Integration with overall functioning picture
Practical implications noted

✔️ Assessment of comorbid conditions

Mental health screening (GAD-7, PHQ-9)
Physical health and sensory assessment
Clear identification of anxiety and mood symptoms
Appropriate medical history taking

✔️ Differential diagnosis

Consideration of social anxiety disorder, ADHD, OCD, personality disorders
Clear reasoning for diagnostic decisions
Evidence-based approach
Integration with assessment findings

✔️ Diagnostic formulation

Clear mapping to DSM-5 criteria (A through E)
Appropriate severity specifiers
Integration of assessment evidence

✔️ Assessment methodology

Clear SIGN 145 compliance statement
Appropriate instrument selection
Transparent assessment process
Evidence-based approach

✔️ Care planning

Immediate (0-3 months), medium (3-12 months), and long-term (12+ months) recommendations
Specific workplace and therapeutic recommendations
Clear referral pathways
Practical guidance provided

✔️ NHS Service integration