UNIT 4 REPORT WRITING AND
RECIPIENT OF REPORT
Structure
4.0 Introduction
4.1 Objectives
4.2 The Psychological Report
4.3 Communicating Assessment Results
4.4 General Guidelines
4.4.1 Length of the Report
4.4.2 Degree of Emphasis
4.4.3 Domains
4.4.4 Deciding What to Include
4.4.5 Raw Data and Quantitative Scores
4.4.6 Client Feedback
4.5 Models of Psychological Reports
4.5.1 Level of Reports
4.6 Format for Psychological Reports
4.6.1 Referral Question
4.6.2 Evaluation Procedures
4.6.3 Behavioural Observations
4.6.4 Background Information
4.6.5 Test Results
4.6.6 Impressions and Interpretations
4.6.7 Summary and Recommendations
4.7 Future Perspectives and Conclusions
4.8 Let Us Sum Up
4.9 Unit End Questions
4.10 Suggested Readings
4.0 INTRODUCTION
The psychological report is the end product of assessment. It represents the
clinician's efforts to integrate the assessment data into a functional whole so that
the information can help the client solve problems and make decisions. Even the
best tests are useless unless the data from them is explained in a manner that is
relevant and clear, and meets the needs of the client and referral source. This
requires clinicians to give not merely test results, but also interact with their data
in a way that makes their conclusions useful in answering the referral question,
making decisions, and helping to solve problems.
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An evaluation can be written in several possible ways. The manner of presentation Report Writing and
Recipient of Report
used depends on the purpose for which the report is intended as well as on the
individual style and orientation of the practitioner. The format provided in this unit
is merely a suggested outline that follows common and traditional guidelines. It
includes methods for elaborating on essential areas such as the referral question,
behavioural observations, relevant history, impressions (interpretations), and
recommendations. In this unit we start with a definition and description of what
a psychological report is and how to communicate assessment results etc. Then
we present the general guidelines of writing a psychological report which includes
the lenth of the report, degree of emphasis, domains etc. Then we discuss the
models of psychological report and the levels of report which includes three
levels. This is followed by a section on format of psychological report.
4.1 OBJECTIVES
After completing this unit, you will be able to:
• Explain what psychological report is;
• Provide the general guidelines for psychological report;
• Describe how to communicate assessment results;
• Explain the general guidelines for writing the report;
• Elucidate the models of psychological report and the levels of report;
• Analyse the format of psychological report; and
• Discuss the future prospects of psychological report.
4.2 THE PSYCHOLOGICAL REPORT
The psychological report presents an opportunity for the professional psychologist
to present the results of assessment in a case focused, problem solving manner.
Its major purpose is to help the referral source make decisions related to the
client. It thus represents the end product of assessment. An ideal report will be
written according to general guidelines and in a flexible but predictable format.
The most frequent categories of reports are centered around questions related to
intelligence / achievement, personality / psychopathology, and neuropsychology
areas. Additional, less frequent categories include adaptive / functional,
developmental, neuro behavioural, aphasia, and behavioural medicine / rehabilitation.
The most frequent general issues relate to diagnosis and answering which type of
treatment would be most effective for a given client. Each of the various categories
of assessment require different types of assessment instruments, knowledge related
to the type of difficulty, awareness of the context( educational, legal, medical,
rehabilitation, forensic ),and knowledge of the various resources available in the
community. This knowledge will then be integrated into the report in order to
make it more problem focused and relevant to the referral source.
4.3 COMMUNICATING ASSESSMENT RESULTS
After testing is completed, analysed, and interpreted, the results are usually first
communicated orally to patients and other interested parties. Results are 55
Psychodiagnostics in communicated to others only with the explicit permission of the person unless
Psychology extraordinary conditions are involved (e.g., the patient is gravely disabled).After
a psychological evaluation, the psychologist will often schedule a feedback session
to show the patient the results, explain the findings in understandable language,
and answer all questions. Often psychologists must also explain their assessment
results to other interested parties such as parents, teachers, attorneys, and
physicians.
In addition to oral feedback, the psychologist typically prepares a written report
to communicate test findings. Most testing reports include the reason for the
referral and the identification of the referring party, the list of assessment instruments
used, actual test scores (such as percentile ranks), the psychologist's interpretation
of the scores and findings, a diagnostic impression, and recommendations. It is
important to ascertain the audience for whom the report is being written.
A report directed to another mental health professional may be very different from
one to a school teacher or a parent. Most psychologists avoid professional jargon
so that their reports will be understandable to non psychologists. Psychologists
also must handle reports confidentially and send them only to appropriate persons.
4.4 GENERAL GUIDELINES
4.4.1 Length of the Report
The length of the report varies considerably across various referral settings.
Traditionally, psychological reports have been between four and seven single
spaced pages. In medical contexts where time efficiency is crucial, psychological
reports rarely exceed two pages. However, psychological reports in a wider
number of contexts also appear to be getting shorter due to the cost containment
and time efficiency demands of managed healthcare. In contrast, legal contexts
demand far more detail, require greater accountability, typically have more complex
referral questions, and involve more flexible, ample methods of reimbursement. As
a result, reports tend to be 7-10 pages and sometimes even longer.
Reports are therefore influenced by and formatted according to the conventions
of other health professionals working within the contexts psychologists write for.
4.4.2 Degree of Emphasis
A well written report also pays particular attention to the degree of emphasis
given to various points. Sometimes, the evidence for a conclusion will be consistent,
strong, and clear and this can then be stated accordingly in the report. Other
information might be more speculative and should be written with an appropriate
degree of tentativeness.
4.4.3 Domains
Test interpretations are ideally presented and organised around specific domains.
The selection of which domains to include should be driven by the types of
questions the referral source is requesting. These questions largely determine the
types of assessment tools used and types of questions asked of the resulting data.
Since each client is different and lives within a different context, the number of
domains will vary considerably. Within a psycho educational context, relevant
domains might revolve around cognitive ability, level of achievement, presence of
56
a learning disability, or learning style. In contrast, a report written to assess Report Writing and
personality / psychopathology might focus more on such areas as coping style, Recipient of Report
level of emotional functioning, suicide potential, characteristics relevant to
psychotherapeutic intervention, or diagnosis.
Sometimes test results are presented in a test by test fashion. This has the advantage
of [Link] it clear where the data came from. However, it runs the risk of being
overly data / test oriented rather than person oriented. Research has consistently
indicated that readers of reports do not feel this style is 'user friendly' . In addition,
it indicates a failure to integrate data from a wide number of sources and suggests
that the practitioner has not adequately conceptualised the case. It also encourages
a technician oriented role rather than one in which a knowledgeable clinician
integrates a wide array of information to help solve a client's problem.
4.4.4 Deciding What to Include
Consistent with the above themes, deciding what include is largely determined
by the referral source. One general principle is that material should only be
included if it helps to further understand the client. In this respect, what is unique
rather than [Link] average is usually more important. For example, describing a
client's appearance is typically not useful if they made modal responses to the test
material and were dressed in average appropriate clothes. In contrast, a client
who was obsessively concerned with accuracy (ignoring time concerns) and dressed
in an unusually formal fashion does provide useful behavioural observations. These
. observations also help to place test scores in a wider context, give information
related [Link] style, and an indication of their personality type.
4.4.5 Raw Data and Quantitative Scores
Generally raw data and quantitative scores should be avoided in the impressions
/ interpretations section of the report. They can potentially make the report seem
overly technical and cluttered. Sometimes, however, providing concrete behavioural
observations or actual responses to selected items (i.e. MMPI-2 critical items)
can make abstract points seem more immediate and insightful into the content of
the person's thought processes. This can serve to balance out more high level
abstractions. In addition, providing a clear statistic such as a percentile can
sometimes make a description seem more clear and accessible. For example, a
report might describe how a client with an average IQ had a quite low auditory
memory. Stating they only scored in the '5th percentile' (or 'only five people out
of a hundred scored in this range') call provide some precision into the magnitude
of their difficulties.
4.4.6 Client Feedback
One of the crucial roles of a psychological report is to assist in providing client
feedback. This is in accordance with client advocacy legislation and the American
Psychological Association's ethical guidelines in that clients should know the types
"'~-
of information and recommendations being made about and for them. Such
N
"t-
feedback is expected to be clear, accurate, direct, and understandable. This
, I
W means the results need to be phrased in everyday language rather than formal
o
Q. psychological terminology. There has also been increasing evidence that well
:e integrated client feedback has clear therapeutic benefits. Thus the report (and
related feedback) can potentially become an integral part of therapy itself. While
feedback is typically verbal, an important option is to design the written report, 57
Psychodiagnostics in or at least an edited version of the report, in such a way as to be of optimal
Psychology
benefit to the client.
Self Assessment Questions
1) Define and describe psychological report.
2) What features are included in the psychological report?
3) Delineate the general guidelines for psychological report writing.
4.5 MODELS OF PSYCHOLOGICAL REPORTS
There are many models / approaches to psychological reports. Some of the
models of reports are discussed below.
The three models for psychological reports to be discussed are the
• The Test Oriented Model,
• The DomainOriented Model, and
• The Hypothesis Oriented Model.
In the Test Oriented Model, results are discussed on a test-by-test basis. Each
test is listed by name and significant results for that test are presented. Each test
is generally discussed in a separate paragraph. Little or no effort is made to
compare and contrast data between the various tests (at least not in the "Results
of Assessment" section). The strength of this approach is that it makes clear the
source of each piece of data. This could be important in certain settings, such as
forensic reports. The weakness of this model is that the reader's attention becomes
focus sed on the tests, rather than on the client's adaptive functioning.
It also communicates to the reader that psychological assessment is a low-level,
technical skill which involves little more than giving the test and copying some
interpretive statements out of a manual. It ignores the role of the psychologist as .
the integrator of the test data; a professional who brings to bear his knowledge
of how the test was constructed, how it Wasnormed, limits to generalis ability of
test data, and how to use the data in a theoretical/conceptual manner to better
understand the client. The Test Oriented Model was used extensively in past, but
58 has become increasingly unpopular in recent years.
In the Domain Oriented Model, results are grouped according to abilities or Report Writing and
"functional domains". Separate paragraphs are usually devoted to such topics as Recipient of Report
intellectual ability, interpersonal skills, psychosocial stressors, coping techniques,
intrapersonal needs, motivational factors, depression, psychotic features, etc. This
model is useful when there is no specific referral question and you're not certain
what use will be made of your data. For example, little background information
may beavailable on a newly admitted patient. You're not sure why he was
admitted or what factors precipitated the admission. Therefore, it is hard to know
which portions of your data will be useful to the treatment team. The Domain
Oriented Model is also co~on in neuropsychological reports, where a variety
of providers may eventually become involved in the case. Each provider will focus
on separate parts of the report to assist in a specific aspect of intervention. This
approach is also helpful when assessment is being used to monitor treatment
progress. It allows you to monitor changes in the client's functioning across a wide
variety of areas'; The weakness of the Domain Oriented approach is that the
reader may be presented with a lot of information that has little relevance to his
intended intervention. He may become so distracted by parts of the report he
doesn't understand, that he fails to focus on information which could be helpful
to him. This model is sometimes pejoratively referred to as a "shotgun" approach,
referring to its apparent effort to hit all the possible target issues.
In the Hypothesis Testing Model, results are focussed on possible answers to the
referral question(s). The idea is to present a hypothesis in the "Purpose for
Evaluation" section, then present data systematically to support or refute the
hypothesis. Separate paragraphs in the "Results of Evaluation" section address
theoretical/conceptual issues by integrating data from the history, mental status
exam and behavioural observations with data from all the tests. Tests are rarely
mentioned by name. For example, information from scale 2 on the MMPI-2 may
be combined with interpretive data from the MCMI dysthymia scale. If the
integration of this information is consistent with the history and the mental status
exam, it is included in a paragraph dealing with depression. The strength of this
model lies in its efficiency and concise focus on the referral problem. The reader
isn't distracted by unrelated details. The primary weakness of the model is that
you don't report some of the information which is unrelated to the "purpose of
the evaluation" but which could potentially be useful to other disciplines.
4.5.1 Levels of Reports
Having covered the issue of report Models, this discussion will now turn to
"levels" of reports. Three levels of reports, viz., level I, level 2and level 3 will
be covered.
A "Level One" report is the copied out of the manual level. The interpretive data
come directly from the manual (or computer print out) and usually follow the
format. This makes for a conceptually weak report and may actually do more
harm than good for the client. Keep in mind that many of the referral agents will
have little understanding of the limits to generalis ability and external validity of
, "raw" test data. This level of report is only appropriate when there are extenuating
circumstances which make it impossible to interview the patient or to obtain .
background information. In those cases the report should be clearly qualified with
a statement to the effect that.. .."These results represent a blind interpretation of
test data and should be considered tentative until confirmed by subsequent clinical
data or background information". 59
Psychodiagnostics in A "Level Two" report represents the minimum level of conceptual input which
Psychology should be used for most purposes. Of all the possible interpretive' hypotheses
generated by the test, the only ones included in the "Results of Evaluation" are
those that have been confirmed (either by the history or in the clinical interview). ,
A "Level Three" report represents the highest level of conceptualization. Its format
is similar to a Level Two report. However, it also presents a theoretical
conceptualisation of the problem. Ideally, this report will integrate all available
information to:
• describe the nature of the problem and how it developed over time
• describe factors which influence and reinforce the problem
• describe any recent exacerbating factors which led to the referral
• provide suggestions for intervention based on the client's strengths,
. weaknesses, and coping skills.
Self Assessment Questions
1) What are the various models of psychological report?
............. ..............................................................................................•....
'
.................................................................................................................
2) Discuss the domain oriented model.
3) Elucidate the hypothesis testing model.
4) Discuss the three levels of report writing.
4.6 FORMAT FOR PSYCHOLOGICAL REPORTS
There are various ways of organising a psychological report. Some practitioners
prefer to use an informal, relatively unstructured letter format. This is especially
appropriate when the report will be seen by a single referral source and the
referring person is known to the practitioner. Other reports might be more
appropriately organised around quite structured headings (i.e. 'Referral question',
60
Report Writing and
'Test results', 'Summary and recommendations'). Some reports might demand
Recipient of Report
(and practitioners prefer to include) an extensive history whereas others might
minimize the history in favour of spending relatively greater time elaborating on
impressions and interpretations. Given the recent trends towards treatment planning
and demonstrating the practical, every day relevance of assessment, some reports
might place relatively greater emphasis and length into providing concrete, specific
recommendations for psychotherapy planning, vocational training, educational
intervention, or neuropsychological rehabilitation.
Even if reports do not formally designate specific headings and subheadings, they
still typically include a predictable series of content areas. The following listing
provides an outline of typical areas (from Groth Mamat, 1999;Williams & Boll,
2(00):
Name:
Age (date of birth):
Sex:
Ethnicity:
Date of report:
Name of examiner:
Referred by:
i) Referral question
ii) Evaluation procedures
iii) Behavioural observations
iv) Background information
v) Test results
vi) Impressions and interpretations
vii) Summary and recommendations
An additional feature is an indication at the top of the report that the report is
'Confidential'. The report should conclude with the signature, name, and title of
the author. This is crucial since it indicates that responsibility for the contents of
the report is being formally acceptedby the author. Identifying information is fairly
straight forward (name, age, sex, etc\) but the additional features (I-VII) require
elaboration. \
4.6.1 Referral Question
The referral question sets the stage for the rest of the report. It is therefore
especially important to make sure it is as clear and specific as possible (i.e. 'My
understanding is that you would like me to evaluate Mr. X with particular reference
to the nature and severity of his deficits, the extent of care he would require,
ability to work, personality functioning, and the likelihood of any further
improvement'). Often clarifying the referral question will require discussions with
the referral source since it is not unusual to have an initially poorly articulated (or
at least partially developed) referral question. One means of assisting with this is - 61
Psychodiagnostics in to ask the referral source what decisions they need to make related to the client.
Psychology Sometimes discussions with the referral source will mean indicating the sorts of
questions that can and cannot realistically be answered through formal assessment.
Such discussions may even result in a mutual decision that formal assessment is
not appropriate for the case. A clearly articulated referral question will carry
through to the rest of the report in that it provides a frame of reference for this
material as well as a rationale for what is relevant to include in the sections on
background information (history), impressions / interpretation, and especially the
summary / recommendations section.
One effective technique is to create bulleted points in the summary, each of which
provide a clear answer to each of the referral questions. However, the points
need to be consistent with material presented previously in the impressions /
interpretation section. A nice beginning to the referral question section (and the
report in general) is to make a brief, succinct, orienting, statement related to the
client (i.e. 'Mr. X is a 36year old, white, right handed, married male with a high
school education who sustained a severe, diffuse closed head injury on April 12,
1998').
4.6.2 Evaluation Procedures
The evaluation procedures section is simply a listing of the various instruments
used. Sometimes, particularly in legal settings, this includes the date when
administered and the length of time they took to complete the test. It is sometimes
useful to include the total time involved in the entire evaluation. If the report relied
on previous records (academic, vocational, legal, medical), then the dates and, if
relevant, the authors of the reports should be given (i.e. 'In addition, I reviewed
the following reports by .. .').
4.6.3 Behavioural Observations
Often behavioural observations can provide a useful context for understanding
test data. For example, low scores on cognitive tests may be the result of low
motivation or perhaps a problem solving style that sacrifices speed for accuracy.
These and related behavioural observations can be noted in the behavioural
observations section. Behavioural observations should generally be kept concise
and relevant. They should also refer to concrete, obsyrvable behaviours rather
than either high level abstractions or conclusions about the client. Thus, it would
be preferable to state that the client moved slowly and they were self critical (i.e.
'the client continually commented that they weren't able to do very well') rather
than to make inferences (i.e. 'the client appeared depressed'). Inconsistencies in
the client's behaviour might also be useful to note. These might include a young
person who acts older than their stated age or a person who says they feel fine
butappear anxious and defensive. Additional domains of behavioural observations
include attitude toward the examiner and test situation, attitudes toward self,
reaction to praise, reaction to failure, motor coordination, reaction time, and
behaviours related to speech and language.
4.6.4 Background Information
One of the potentially most useful functions of the professional psychologist is to
provide descriptions of relevant background information. This might be
particularly important in a medical context where physicians neither have the time
nor the appropriate training to access important client information. At the same
62
time, the background information section should avoid being overly inclusive. For Report Writing and
example, it is unlikely to be useful to provide a detailed developmental history for Recipient of Report
an adult who is seeking vocational assessment. On the other hand, a detailed
developmental history would be essential for an adolescent referred to assess
possible learning disabilities. It is usually important to clarify where the information
came from (i.e. 'The client reported that ... ' or 'The report of 3/6/98 by Dr.
Y indicated that ... '). Possible domains for history taking and inclusion in the
background information section include the following: history of the problem,
medical history, vocational / employment background, family background, personal
history (infancy, early/middle childhood, adolescence, early/middle adulthood, late
adulthood), and miscellaneous areas such as fears, self concept, recurring dreams,
or specific memories.
4.6.5 Test, Results
Some reports include a test results section which lists the actual scores on the
tests. If this is done, it is often useful to translate the scores into percentiles to
enable readers to more easily understand the meanings of the test scores. A
further related strategy is to develop a profile sheet depicting relative high and low
performances. Some times these might nave cutoffs for such categories as 'impaired',
'superior', or 'dysfunctional'. In some cases the test results / scores are placed
in a section within the body of the report itself. In reports, the 'test results' section
is included as an' appendix. It is also not unusual for reports to exclude the actual
.test data. This is especially the case in medical settings where concise reports are
greatly valued. Actual test scores might also be excluded if it is known that the
referral source is neither trained in, nor interested in, seeing the actual scores.
4.6.6 Impressions and Interpretations
The main body of the report is contained in the impressions and interpretation
section. It represents an integration of fmdings based not only on test scores, but.
also behavioural observations, relevant history, relevant records, and additional
available data. The importance of presenting the information according to domains
rather than test by test has already been discussed. The selection of domains is
based on answering the referral question. If ability / IQ measures have been
measured, it is traditional to place these first since they usually provide an important
context for understanding most other types of information. Most of the time actual
IQ scores are given along with percentiles and intelligence classification (Low
Average, Superior, etc.). Some authors might prefer to provide an estimate of the
range of possible error of IQ scores by including the Standard error of Measure.
In contrast, other authors might consider this to be too technical and test oriented
and decide to omit this information. If there is a chance the IQ scores might be
misunderstood, then they are sometimes excluded and only the percentiles and
intelligence classifications are given.
Different types of referral categories, along with the specific referral questions, will
determine the additional domains to include. For example, when assessing
intellectual/achievement types of referrals; important domains might include general
cognitive ability, specific strengths and weaknesses, level of achievement, aptitudes,
learning style, interests, and possibly vocational interests. A neuropsychological
report might not only focus on cognitive abilities and achievement but also learning!
memory, language functions, attention,visuo constructive abilities,executive function,
emotional functioning, and potential and strategies for cognitive rehabilitation.
63
Psychodiagnostics in 4.6.7 Summary and Recommendations'
Psychology
The most valuable section is usually the summary and recommendations. The
importance of this section is that sometimes it is the only section read by allied
health professionals concerned with time efficiency. The summary provides an
opportunity for the practitioner to succinctly state the main conclusions of the
report. As indicated previously, the summary section also provides an opportunity
to make sure each one of the referral questions have been addressed. The
recommendations are an opportunity to provide person focused suggestions on
solving specific problems. A clear research finding is that reports are typically
rated as most useful if the recommendations are highly specific rather than general.
Thus a statement such as the 'client should begin individual psychotherapy' is not
as useful as one that states the 'client is likely to benefit most from weekly
sessions of individual psychotherapy using strategies to decrease their level of
subjective distress, enhance social supports, and increase their level of awareness
related to self defeating patterns in interpersonal relationships' . Once a report has
been submitted, follow up contact with the referral source is advisable in order
to provide ongoing feedback related to the accuracy and usefulness of the report
as well as help facilitate the actual implementation of the recommendations.
A sample of a format
PSYCHOLOGICAL EVALUATION
(Facility Name Here)
RupaKumar Dates of Evaluation: 3.6.2011
Case No.: Building No.: 11
Admission Date: 4.6.11 Date of Report: 3.6.11.
Purpose for Evaluation: Rather than "Reason for Referral" the first section for
the report is better called "PURPOSE FOR EVALUATION." This gives the
clinical psychologist a lot more flexibility. If you us "Reason for Referral" is used
the psychologist has to copy whatever the consult says. Unfortunately, many
consults ask questions which tests can not answer (or else they do not ask any
question at all).
This section should be used to briefly introduce the patient and the problem.
Begin with a concise "demographic picture" of the patient. (e.g., This is the third
inpatient admission for this 32 year old, single, white female who has 13 years of
formal education and is employed as a beautician. She was admitted due to
symptoms of major depression with possible psychotic features.)
Use this section to tell your reader what issues you will address in the body of
the report. The reader will then know on what issues to focus, and he can be
forming his own impressions while he is reading the report .. (e.g., The purpose
for the current evaluation was to screen for evidence of psychosis and clarify the
nature of the underlying depressive disorder.) In sum, use this section to "pose
a question," which you will ~nswer in the "SUMMARY" section.
Finally, if the evaluation takes more than 5 days to complete, you should put
a progress note in the patient's chart giving preliminary test results. For
example, you might conclude the "PURPOSE FOR EVALUATION' section of
64 your report with, "Preliminary results were reported in the patient's progress
notes on 3.6.11. The current report will supplement and elaborate upon those Report Writing and
preliminary findings." Recipient of Report
Assessment Procedures: Refer to this section as "ASSESSMENT
PROCEDURES" rather than "TESTS ADMINISTERED." This allows the
psychologist to include the Mental Status Exam and the Clinical Interview as two
procedures. This also helps communicate to referral sources that the psychologist
do more than give some tests and copy interpretive statements out of a manual.
It lets them know that the psychologist's evaluation is a professional integration
of information from a variety of sources. Be sure to also note who gave the tests
and how long it took. These issues are important if a case ever goes to court.
e.g.: Millon Clinical Multiaxial Inventory-Ill (MCMI-Ill)
Minnesota Multiphasic Personality Inventory-2 (MMPI-2)
Mental Status Examination
Review of Prior Psychological Assessment
Review of Prior Medical Records
Clinical Interview
This patient participated in 3 hours of testing and a 1 hour diagnostic interview.
Tests were administered by Jim Smith, M.S. and interpreted by Dr. Ram Kishore
and interpreted by Dr. Lavanya Seth.
Background Infonnation: In this section present paragraphs dealing with family,
social, legal, medical, family mental health, etc. issues, if needed. Only include
those issues; that are relevant to the "questions" posed under "PURPOSE FOR
EVALUATION." Excessive, unnecessary details will distract the reader from the
case that is being built in support of the psychologist's conclusions. Whenever
possible, maintain chronological order when presenting background information.
Next describe the patient's history of substance abuse / mental problems, and
mental health care in CHRONOLOGICAL order. Where possible, provide enough
details of prior intervention efforts to clarify what was attempted and whether it
was successful.
The psychologist's goal is to encourage replication of prior successes and / or
avoid duplication of prior treatment failures. Also, be sure to describe the patient's
behaviour and level of adaptive functioning BETWEEN prior interventions. These
details will help give the treatment team an idea of what "target level" of adaptive
functioning to look for in the current intervention.
Follow with a paragraph describing the onset and development of the present
illness / exacerbation. Let the reader get an idea of how the current admission
compares to prior admissions and what specific events precipitated the current
admission. End this section with a brief paragraph summarizing staff observations,
patient behaviour, level of motivation, etc. during the current admission. Keep in
mind that objective observations by professional staff are one of the best sources
of data. Conclude with a sentence indicating medications being taken at the time
of testing.
Mental Status Examination: Focus on one's own observations and impressions.
This section of the report should focus on the psychologist's objective evaluation.
Avoid quoting the patient's opinion of his own mood, affect, etc. It is also best
to avoid mixing in background information or test information with this section.
A typical MSE for a 'normal' patient might read: 65
Psychodiagnostics in Results of mental status examination revealed an alert, attentive individual
Psychology who showed no evidence of excessive distractibility and tracked
conversation well. The patient was casually dressed and groomed.
Orientation was intact for person, time and place. Eye contact was
appropriate. There was no abnormality of gait, posture or deportment.
Speech functions were appropriate for rate, volume, prosody, and fluency,
with no evidence of paraphasic errors. Vocabulary and grammar skills
were suggestive of intellectual functioning within the average range.
The patient's attitude was open and cooperative. His mood was euthymic.
Affect was appropriate to verbal content and showed broad range.
Memory functions were grossly intact with respect to immediate and
remote recall of events and factual information. His thought process was
intact, goal oriented, and well organised. Thought content revealed no
evidence of delusions, paranoia, or suicidal or homicidal ideation. There
was no evidence of perceptual disorder. His level of personal insight
appeared to be good, as evidenced by ability to state his current diagnosis
and by ability to identify specific stressors which precipitated the current
exacerbation. Social judgment appeared good, as evidenced by appropriate
interactions with staff and other patients on the ward and by cooperative
efforts to achieve treatment goals required for discharge.
Resuls of Evalution: The idea is to present a hypothesis in the "PURPOSE
FOR EVALUATION" section, then present data systematically to support or
refute the hypothesis. Separate paragraphs in the "RESULTS OF EVALUATI0N"
section address theoretical / conceptual issues by integrating data from the history,
mental status exam and behavioural observations with data from all the tests.
Specific tests are rarely mentioned by name. For example, information from
scale 2 on the MMPI-2 may be combined with interpretive data from the MCMI-
ill dysthymia scale. If the integration of this information [Link] with the
history and the mental status exam, it is included in a paragraph dealing with
depression.
SummarylRecommendations: Begin by specifically answering the questions you
posed under "PURPOSE FOR EVALUATION." Then elaborate as much as
needed to present your conceptualisation of the case. It's fine to include DSM.
diagnostic impressions, but your summary of the patient's psychological makeup
is far more important. If you do include DSM labels, be sure to provide enough
detail in the body of the report to support the diagnostic criteria as described in
DSM. Any recommendations for treatment can also go here. For example:
Results of psychological evaluation reveal an extended history of alcohol
abuse and a psychotic disorder characterised primarily by disturbance of
thought content, with relative integrity of thought process and no clear
indication of perceptual disturbance. The current clinical presentation
appears to represent an acute exacerbation of a chronic psychotic
disturbance which had its onset approximately 8 years ago. Currently, the
patient appears to remain extremely distressed, anxious, paranoid, and
delusional, despite self reports to the contrary. He lacks sufficient capacity/
motivation to rely on external supports and lacks sufficient personal insight
to cope independently at present. The patient appears to be attempting
to cope with his illness using extreme guardedness and withdrawal. During
recent months he has shown no signs of aggressive ideation and is not
66 believed to be a physical risk to himself or others at present.
It is recommended that efforts to establish a trusting relationship with this Report Writing and
patient be continued, in order to help him cultivate a more adaptive Recipient of Report
coping/defensive patte~. Individual therapy will be more productive than
group interventions. Once his guardedness has been relaxed, it will likely
be beneficial to explore psychosocial issues present at the time The patient
lost his job, as these appear to have partially precipitated the current
psychotic exacerbation. Additionally, the patient will benefit from
encouragement to explore the social and adaptive significance of his
substance abuse history.
Self Assessment Questions
1) What is meant by referral questions?
2) Elucidate how to write evaluation procedures.
3) Describe behavioural observation in a psychological report.
4) What type of background information is included in psychological report?
5) What ways the test results are presented in a psychological report?
6) Why is impressions and interpretations are important in a report?
67
Psychodiagnostics in
Psychology 7) What would contain in the summary and recommendations?
4.7 FUTURE PERSPECTIVES AND
CONCLUSIONS
The above guidelines and outline for a psychological report may, in some ways,
appear as a mechanical process. It should also be stressed that the most successful
reports are likely to emerge from clinician and client interactions that are
characterised by a high level of involvement and understanding. This is then likely
to be reflected in a report that is more full, in depth, and captures the complexity
and 'humanness' of the client. Technical skills and mechanical interpretation are
-c •
no substitute for this process. An additional essential quality is that clinicians are
well informed related to the type of problem and overall context the client is
functioning in. Given that there is surprisingly little research on psychological
reports, it would be crucial to expand this research base. The most likely avenue
would be to investigate the interface between research on clinical judgement,
psychometrics, and the ability of clinicians to interface with computer assisted
interpretations in such a way as to increase the accuracy of clinician based
judgements. This would need to be continually evaluated against the relative
usefulness of reports with various referral sources.
4.8 LET US SUM UP
Assessment results are often communicated verbally to interested parties. After a
psychological evaluation a psychologist will often schedule a feedback session to
show the person who was tested the results and explain the findings in language
that is understandable to a non psychologist. In addition to oral feedback, the
psychologist typically prepares a written report to communicate test findings.
Most psychologists avoid professional jargons so that their reports will be
understandable to non psychologists. This unit outlined the way in which the
referral for a psychodiagnostic test evaluation arises, the importance of its
communicative nature, its place in the referral and helping process, and the fact
that it can be focused in various ways. It was also pointed out that any pathology
uncovered by the test data needs to be related to the referral problem. The
particular importance of each section in the psychological report was defined, and
a rationale was presented to reveal the logical inter connections and sequence of
the various sections.
4.9 UNIT END QUESTIONS
I) The psychological report is the end product of -------
2) A report directed to another mental health professional is similartoone to a
68 school teacher or a parent. True or False?
3) The length of the report varies considerably across various referral settings. Report Writing and
Recipient of Report
True or False?
4) One of the crucial roles of a psychological report is to assist in providing -
5) The ~~------- sets the stage for the rest of the report.
6) The main body of the report is contained in the -------:and-
------ section.
7) The test results provide an opportunity for the practitioner to succinctly state
the main conclusions of the report. True or False?
8) Discuss the importance of psychological report?
9) Describe the general guidelines for a psychological report with examples?
10) Describe the format for psychological report by using suitable examples?
4.10 SUGGESTED READINGS
Groth-Marnat, Gary. (2003). Handbook of Psychological Assessment (4thed.).
New Jersey: John Wiley & Sons, Inc.
Murphy, K.R., Davidshofer, CO. (2005). Psychological Testing: Principles
and Applications (61hed.). New Jersey: Pears on Education International.
69
References
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71
NOTES