Tips in Psychological Report Writing
Tips in Psychological Report Writing
3. Tailor the report to the reader with respect to his training, his familiarity with
terms, uses for the report, and what questions he is asking. Address the
referral question. If the question is inappropriate or can not be answered with
psychological assessment, you may need to consult with the referral source
and modify the question. Don't just copy the question from the referral
sheet. Use this section of the report to state the "Purpose of the
evaluation." Word the referral question to cue the reader as to what
confirming/refuting data to focus on while reading the report. Tell him what
case you are building. (e.g., let him know to cue in on the Avoidant Personality
issues.) You don't want him to get to the end of your report, then have to read
it again to see if your conclusions were supported. Let him be forming this
judgement while he reads.
The referral question can help the reader get a better understanding of what
psychological assessment can potentially provide. Address unwritten needs of
referral source, such as objective confirmation of diagnosis, presence/absence
of risk factors for aggression, suicide, etc.
5. Improve report writing with good structure. The goal of the report is to reach a
logical conclusion that answers the referral question(s) and is supported by
valid, reliable data. Use the body of the report to establish credibility for your
conclusions. You have 3 sources of data:
/ BEHAVIORAL OBSERVATIONS \
CLINICAL HISTORY \ MENTAL STATUS EXAM / TEST DATA
\ | /
\ | /
\ | /
\ | /
\ | /
CONCLUSIONS
If any one of these is missing (e.g., test data), you still have two sources of data for the
report!
6. Have a plan or general outline in mind when you start writing. Know where
you're going; what conclusions you're building toward. If you start writing
with the idea that you'll figure out some conclusions when you get to the end
of the report, you'll need to do extensive rewriting to make the report flow
smoothly and to remove the unnecessary details.
7. Within this framework you want the report to flow smoothly, so that minimal
effort is required of the reader to organize the data. Help him assimilate the
information by giving him an efficient structure. Let him concentrate on
understanding the patient, rather than being distracted by trying to "put the
pieces together."
in the Referral Question you told him what information to look for in
the report
now give him a "gestalt", a framework on which to place all the details
you are about to present. Do this with a concise demographic
description at the beginning of the Background Information section.
Let him get a mental image of the patient you are describing. (e.g., This
is the first MSH admission for this 36 year old, single, white female
who has 13 years of formal education and is employed as a sales clerk.)
Use good paragraph structure. The first sentence of the paragraph tells
what the whole paragraph is about. The last sentence sums up the
paragraph.
Be consistent in your form. If you give the details of the first marriage
(or hospitalization, or reasons for medication changes), give the details
of all marriages, etc. Where this isn't possible, let the reader know
which information is not available, or why you elaborated on one event
and not the other.
The patient may have conflicts The patient's difficulty with authority figures
dealing with authority figures. is evident in his multiple expulsions from
school, arrests, and frequent loss of jobs due
to "personality conflicts" with employers.
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11. Where inconsistencies exist between tests (e.g., MMPI-2 vs MCMI-III) try to
figure out WHY there is a discrepancy.
13. Stating that a patient is psychotic tells little about the problem. Be specific...
(e.g., Results of psychological evaluation reveal the presence of a psychotic
thought disorder characterized by disturbed thought process with relative
integrity of thought content, and no clear indication of ongoing perceptual
disturbance.
Be specific about the content of delusions and note whether they are
systematized.
14. Avoid using jargon or terms for which there is little consensus as to their
meaning. State what you observe rather than just saying ....impaired "reality
testing", or that the patient appeared "characterological", "neurotic", or that he
displayed "cognitive slippage", or "perceptual insensitivity."
15. Avoid vague comments that don't really describe the patient or changes in his
status. For example...Rather than saying the patient "improved" on Haldol,
state what changes were observed that suggested improvement. Were there
specific changes in mental status, self care,...etc.?
16. Be sure to use the terms reliability and validity correctly. Misusing these
terms is the psychological equivalent to saying "ain't" in English class and is
second only to, "The data is.." when it comes to destroying your credibility in
the eyes of other psychologists.
17. There is no such thing as an "invalid" MMPI. You can always gather
inferences from the data, even if it's only an explanation of why the F scale
was so high and all the clinical scales are so elevated. In general, you can
avoid confusion by not specifically mentioning the "validity" of the
MMPI. However, if the validity issue is addressed in the report, an appropriate
option might be to say something like... "Results obtained on the MMPI-2
were psychometrically invalid. However, the resulting clinical profile was
partially consistent with the client's history and clinical presentation in
that...." An even more attractive option would be to avoid using the term
validity, and just address the specific reliability/validity points that tend to be
(inappropriately) lumped together under this heading. For example: "The
client responded to objective testing with excessive endorsement of
pathological items, suggesting a deliberate effort to present himself in a
negative manner. He scored particularly low on scales addressing
psychological defensiveness and tended to endorse obvious indicators of
psychopathology much more frequently than relatively subtle indicators of
similar problems. Furthermore, he failed to provide consistent answers to
similarly worded test times, possibly suggesting inattentiveness to the task.)
18. When referring to yourself in a report there is no clear consensus whether you
should use personal pronouns or refer to yourself as "the examiner." Many
psychologists feel that referring to yourself in the third person makes the report
sound more objective and formal. Others (including myself) feel that it makes
the report sound awkward and stilted. One option is to find ways to avoid
references to yourself. For example,
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The patient was angry with The patient voiced frustration and
me for interrupting his hostility over disruption of
scheduled activities on scheduled ward activities.
the ward.
Under Purpose of Evaluation...rather than saying the patient was referred for
psychological evaluation, you could say that he was referred for "psychometric
screening".
The last sentence of the summary could read.. "These results of psychometric
screening should be viewed as tentative, until confirmed by further clinical
data."
20. Rather than having a section called "Tests Administered", I recommend calling
it "Assessment Procedures." Under this section you can then list "Clinical
Interview" and "Mental Status Examination" along with the tests. This helps
communicate to the reader that your evaluation is an integrated evaluation, not
just a list of test results. In this section you might also list "Review of Prior
Psychological Assessment Dated ------", "Interview With Joe Blow (patient's
brother)", "Review of Medical Records."
21. Try to vary your sentence structure, throwing in some dependent clauses. This
will make the report more readable. However, it's best not to get so "flowery"
that its hard to understand. You don't want the reader to have to reread a
sentence to figure out what you are talking about.
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