Report writing & Feedback
HUMA MUGHAL
What is report writing?
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
Possible ways
To avoid shotgun style
Apply case-focused style
Principles
1- Action-oriented language
2- The recommendations in a case-focused report need to
directly relate to what specifically can be done for this
client in his or her particular environment.
They may apply to areas such as occupational choice,
psychotherapy, institutional programs, or additional
evaluation
Current Trend,
Consistent: with the case-focused approach, toward
deemphasizing diagnosis and etiology
An emphasis on current description of the person that are
tied to specific behaviors.
Quality and usefulness of report: practitioner is
knowledgeable about the area or type of issue the client is
experiencing.
Such knowledge helps to increase the depth of the
interpretations and provides relevant information or a
general “map” of the problem area that can be used to
help ensure that all relevant aspects have been covered.
Important to know
GENERAL GUIDELINES for report writing
Length: The typical psychological report is between five
and seven single-spaced pages (Finn, Moes, & Kaplan,
2001). However, the length can vary substantially based
on the purpose of the report, context, and expectations of
the referral source.
Style: The style or “flavor” of a report is influenced
primarily by the training and orientation of the examiner.
The clinician can choose from four general report-writing
approaches: literary, clinical, scientific, and professional
(Ownby, 1997; Tallent, 1992, 1993).
Clinical Approach
The clinical approach focuses on the pathological
dimensions of a person.
Abnormal features,
Defenses, Dynamics involved in maladjustment,
Typical reactions to stress.
The strength of the clinical approach is that it provides
information about areas in need of change and alerts a
potential practitioner to likely difficulties during the course
of treatment.
Presenting Test Interpretations
The hypothesis-oriented model focuses heavily on
answering specific questions asked by the referral source.
The report tends to be highly focused, well integrated, and
avoids any extraneous material.
For example, if a referral source asks whether person X
is brain-damaged, all the interpretations based on the test
data are directed toward answering whether this
hypothesis is supported.
Topics
Common topics are likely to be related to
cognitive functioning, emotional functioning (affect/mood),
and interpersonal relations.
Additional topics include personal strengths, vocational
aptitudes, suicidal potential, defenses, areas of conflict,
behavior under stress, impulsiveness, or sexuality.
Deciding What to Include?
The clinician must strike a balance between providing too
much information and providing too little, and between
being too cold and being too dramatic.
As a rule, information should be included only if it serves
to increase the understanding of the client.
The basic guidelines for deciding what to include in a
report relate to the needs of the referral setting,
background of the readers, purpose of testing, relative
usefulness of the information, and whether the information
describes unique characteristics of the person
Emphasis
General summaries may be given, such as “this client’s
level of depression is characteristic of inpatient
populations,” or the relative intensity of certain aspects of
a client’s disorder may be more specifically discussed.
To continue with the example of depression, a clinician
may discuss the client’s cognitive self-criticisms, degree of
slowed behavior, extent of social support, level of social
skills, or suicidal potential.
Content load
Content Overload
A general guideline is to estimate how much information a
reader can realistically be expected to assimilate. If too
many details are given, the information may begin to
become poorly defined and vague and, therefore, lack
impact or usefulness.
Feedback
current practices are to provide the client with clear, direct,
and accurate feedback regarding the results of an
evaluation
Factors in providing Feedback
First, regulations have supported a growing list of
consumer rights
Second, it might be perceived as a violation if the client
did not receive feedback regarding the results of testing
after he or she had been subjected to several hours of
assessment.
Third, examiners cannot safely assume that the original
referral source will provide feedback to the client. Even if
the referral source does provide feedback, there is no
guarantee that the information will be provided in an
appropriate manner. Thus, the responsibility for providing
feedback is ultimately on the clinician.
Format & Style
Each practitioner needs to develop both the format and
style that most effectively meet his or her client’s and
referral source’s needs. In addition, different assessment
contexts require different styles and areas of focus.
FORMAT FOR A PSYCHOLOGICAL Report
Name: Age (date of birth):
Sex: Ethnicity:
Date of Report:
Name of Examiner:
Referred by:
I. Referral Question
II. Evaluation Procedures
III. Behavioral Observations
IV. Background Information (relevant history)
V. Test Results
VI. Impressions and Interpretations
VII. Summary and Recommendations
The Referral Question
Section provides a brief description of the client and a
statement of the general reason for conducting the
evaluation. In particular, this should include a brief
description of the nature of the problem.
In particular, this should include a brief description of the
nature of the problem
A prerequisite for this section is that the clinician has
developed an adequate clarification of the referral
question. The purpose of testing should be stated in a
precise and problem-oriented manner.
The key should be to find out what the referring person
really wants from the report.
Evaluation Procedures
The report section that deals with evaluation procedures
simply lists the tests and other evaluation procedures used
but does not include the actual test results. Usually, full
test names are included along with their abbreviations.
Often, evaluation includes a review of relevant records
such as medical reports, nursing notes, military records,
police records, previous psychological or psychiatric
reports, or educational records.
Behavioral Observations
A description of the client’s behaviors can provide insight
into his or her problem and may be a significant source of
data to confirm, modify, or question the test-related
interpretations.
These observations can be related to a client’s
appearance, general behavioral observations, or
examiner-client interaction.
Descriptions should be tied to specific behaviors and
should not represent a clinician’s inferences.
Background Information (also Referred to as
Relevant History)
The write-up of a client’s background information should
include aspects of the person’s history that are relevant to
the problem the person is confronting and to the
interpretation of the test results.
In selecting which areas to include and which to exclude, a
clinician must continually evaluate these areas in
relationship to the overall purpose of the report.
A history begins with a brief summary of the client’s
general background. This can be followed by sections
describing family background, personal history, medical
history, history of the problem, and current life situation
Test Results
it may not be necessary to list test scores. Some
practitioners even prefer to completely exclude actually
giving test scores because it might give the impression
that the report is too data/test oriented.
If actual test scores are included, standard (rather than
raw) scores should be the mode of presentation
Impressions and Interpretations
The main body of the report
The areas discussed and the style of presentation vary
according to the personal orientation of the clinician, the
purpose of testing, the individual being tested, and the
types of tests administered.
When actually writing the Impressions and Interpretations
section of the report, the clinician can then review all
findings in a particular topic and summarize them on the
report
Assessment domains by tests administered
Sample grid of Evaluation Procedures
Interview WAIS-III MMPI BDI Rorschach
Validity of results
Cognitive functioning
Emotional controls
Interpersonal relations
Diagnostic impression
Recommendation
Summary and Recommendation
The purpose of the summary subsection is to restate
succinctly the primary findings and conclusions.
The ultimate practical purpose of the report is contained in
the recommendations because they suggest what steps
can be taken to solve problems.
Decisions related to recommendations
Three different levels (Beutler, 1995).
First, decisions need to be made related to the setting or
context (outpatient, day hospital, halfway house, inpatient,
new work environment, change in schools/classes).
Second, consideration needs to be given to developing a
relationship with the client (degree of resistance, level of
insight, interpersonal style, empathy, etc.).
Finally, decisions need to be made about specific
intervention procedures
Report in mental health settings
What is noteworthy in the handling of the test data is that
the bulk of the discussion relating to test interpretation
revolves around projective test findings (Rorschach, TAT,
projective drawing).
RECOMMENDED READING
Armengol, C. G., Kaplan, E., & Moes E. J. (Eds.). (2001).
The consumer-oriented neuropsychological report. Lutz,
FL: Psychological Assessment Resources.
Tallent, N. (1993). Psychological report writing (4th ed.).
Englewood Cliffs, NJ: Prentice-Hall.
Zuckerman, E. L. (2000). The clinician’s thesaurus: A
guidebook for wording psychological reports (5th ed.).
Pittsburgh, PA: Three Wishes Press.
Relevant Queries
