Report Writing Skills
 
Psychological Reports have three main purposes;
 
1) To address a question and answer with important information and an explanation of its impact
A social worker may want an exploration of the client's needs and prognosis, or a prediction of their risk to be violent, abuse children, or relapse to abusing substances. A neurologist may want it to determine the extent to which neurological changes are seen in real life behaviors. A medical doctor, or a lawyer, may want to know to what extent a client is turning emotional distress into physical distress, while a vocational counselor wants to know a client's strengths, weaknesses, and best placement in the job market. A judge might want to know which adult is the better parent in a family. Some employers will want to know how well a person can handle stress, if they should be allowed to carry a gun, or if they are emotionally sound to serve as a counselor or aide to troubled people. Some clients and therapists simply want to understand their client better.

2) To serve as the record for a case
Sometimes the Psychological Evaluation is the only record that's really available on a client. A neurologist might want a detailed documentation of functioning to judge later deterioration by, while a court might want documentation of a client's functioning before making a decision of what they are capable of doing or not.

3) To re-frame the client's case and issues
Sometimes the most helpful thing you can do in a psychological report is explain the client's resistance, highlight some of their struggles, and basically indicate that they are human even if they don't appear it at times. This isn't a very specific goal, but humans write about humans for other humans to learn.

Basic points to keep in mind would include…
  • they have your name on them and you are responsible for their content
  • the client is likely to eventually read it, so ask yourself can they understand it, and would they feel OK reading it?
  • could others who help the client read it and makes sense of it? find it useful?

What do reports contain?
  • Introductory Information including
    • name
    • date of birth
    • age at testing
    • date of testing
    • examiner and supervisor names and degrees
  • Reason for Referral and background records reviewed
  • Background
    • family history and any abuse or trauma
    • developmental history
    • educational history
    • mental and physical health
    • history of presenting problem
    • previous reports of evaluations
    • recent updates to case history
  • Observations and Mental Status Exam
    • observations of speech, thought quality, appearance, motivation…
    • clear behavioral descriptors (e.g., "She bit her nails…")
    • interpretations separate (e.g. and thus appeared somewhat anxious.")
  • Results of testing
    • skills not scores only
    • abilities and areas, not just tests
    • characteristics and traits, strengths and weaknesses
  • Summary (e.g., "In review, Mr. Smith was a 32 year old man referred by…")
  • Conclusions
    • offer case conceptualization
    • address referral questions
    • add previously unnoted issues
    • pave the way for recommendations and expectations
    • diagnosis (possibly)
  • Recommendations
    • what would be helpful
    • any tips needed to maximize success
    • any timelines, concerns about progress, or limitations
  • Closing
    • thank you for the referral…
    • if anyone else should assess this person…
    • contact me…


Harvey offers that the main problem in writing reports is readability. Professionals write at too high of a grade level for many of their readers to understand. This is very dangerous, given that if it is too difficult to read, the reader may ignore it. This limits the ability of reports to serve their three main purposes, and means a client and you went through a lot of work to no productive end.

Consider the following. What's the difference between:
Jay has normal intellectual ability.
and
Jay demonstrated average intellectual skills at this testing.
On an intelligence test, Sarana showed serious deficits.
and
On a test of cognitive abilities normed on majority children, Sarana's performance fell in the deficient range.
Tawan's score fell below the mean for this test.
and
Tawan's score fell around the median of a sample of children his age; that is, his performance was in the middle between the lowest and highest scoring child.
Phil scored at the 85th percentile on the validity scale of this test.
and
Phil presented himself in a highly favorable light; his score fell at the 85th percentile, indicating that he rated his skills and abilities more favorably than 85% of the respondents to this questionnaire.
Sharon's IQ was 93+7.
and
Sharon obtained an Intelligence Quotient on the WISC-III of 93. This means that her "true" IQ lies somewhere between 86 and 100; her intellectual abilities are thus Low Average to Average.


Disclaimers to testing
I and some of the other doctors in my group have started putting the following "disclaimer" in reports. What do you think?
For Adults:
 
It should be noted that "intelligence" is defined by the test used here as the global capacity of the individual to deal effectively with the environment. IQ tests sample skills in select areas in order to estimate overall intelligence. Thus, IQ scores and intelligence are not the same thing. The scores obtained here should be used to predict the client's educational and vocational functioning. Use of these scores beyond that should be approached with caution, as cultural values, educational opportunities, physical health, emotional troubles, and living environment can all impact scores.

For Children:
 
The reader should note that intelligence is often defined as the global capacity of a child to deal effectively with their environment. IQ tests sample skills in select areas in order to estimate current intellectual functioning. Thus, IQ scores are not the same thing as "potential" or "intelligence." However, when part of a psychological assessment, results can be used to understand adjustment, identify learning needs, and predict educational success (i.e., years completed in school, grades, and vocational level). Such predictions, however, are impacted by poverty, bilingual environments, experiences with parents, and stability of the home life. Results are considered to be relatively stable for one year, and use of these scores after that is not recommended; changes in the child's home, educational setting, and physical health can significantly change these scores. Use of these scores to estimate a child's functioning in others areas should be approached with caution, especially with bilingual children or children of cultural minority groups.