Example 2: 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: Six 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)
Adult Autism Specialist (HCPC: PYL67890)

✔️ Comprehensive developmental history

Requirement: Detailed developmental history using validated tools
Evidence:

ADI-R administration with sister as informant
Comprehensive background covering early development, school years, university, career
Detailed examples of early autism traits
Clear developmental timeline

✔️ Direct clinical observation

Requirement: ADOS-2 or equivalent structured observation
Evidence:

ADOS-2 Module 4 administered by qualified clinician
Detailed scoring (Social Affect: 8, RRBs: 2, Total: 10)
Recognition of compensatory strategies during assessment
Clear autism spectrum classification

✔️ Cognitive assessment

Requirement: Assessment of intellectual functioning
Evidence:

Full WAIS-IV battery (FSIQ: 127 - Superior range)
Detailed cognitive profile across all domains
Clear ruling out of intellectual disability
Integration with diagnostic formulation

✔️ Adaptive functioning assessment

Requirement: Assessment of daily living and adaptive skills
Evidence:

Vineland-3 administration across all domains
Detailed scoring showing relative difficulties in socialisation (82)
Integration with overall functioning assessment
Practical implications discussed

✔️ Assessment of comorbid conditions

Comprehensive mental health screening (GAD-7, PHQ-9)
Physical health assessment including sensory evaluation
Occupational burnout assessment
Clear identification of secondary conditions

✔️ Differential diagnosis

Systematic consideration of GAD, depression, ADHD, personality disorders
Clear reasoning for ruling out alternative diagnoses
Evidence-based clinical reasoning
Integration with assessment findings

✔️ Diagnostic formulation

Clear mapping to both ICD-11 and DSM-5 criteria
Detailed evidence for each diagnostic criterion
Appropriate severity specifiers
Recognition of compensatory strategies

✔️ Assessment methodology

Clear statement of SIGN 145 compliance
Detailed instrument list with administration details
Evidence-based assessment approach
Appropriate tool selection for adult presentation

✔️ Comprehensive care planning

Immediate (0-3 months), medium (3-12 months), and long-term (12+ months) recommendations
Specific, actionable guidance
Clear timelines and referral pathways
Integration with existing services

✔️ NHS Service integration