Chapter 8

Report Writing and Recipient of Report

The Psychological Report

The psychological test report results from a process that starts with a referral source.

The problem of the patient may be critical, and the referral person helping with the problem must
be able to utilize the psychologist’s input. It must be written in a way that corresponds to the
reader’s level of understanding and training.

A well-written report will not merely report test results but will also incorporate a wide array of
relevant information. A psychological report should be carefully crafted with attention to detail. The
caliber of the report can be initially evaluated by examining typographical errors, use of vague
jargon, careless mistakes, and lack of detail.

Report writing is one of the most important skills a mental health professional can learn. The
psychological report typically is the only mechanism of communicating a client’s psychological,
cognitive, personality, adaptive, and other types of functioning. A mediocre report reflects directly
on the perceived clinical ability of the writer. A concise, insightful, information-filled report speaks
highly about the clinician and typically will generate future referrals.

Communicating Assessment Results

Most testing reports includes

• 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
• recommendations

General Guidelines

Length of the Report

Psychological reports vary in length.

The average psychological report is from five to seven single-spaced pages.

A typical legal report is 7-10 single-spaced pages, although some legal reports can be as long as 20
pages.
If a clinician includes all of the information gathered about a client, the report could easily reach 25
or more pages.

Degree of Emphasis

A well written report also pays particular attention to the degree of emphasis given to various
points

Domains

Test interpretations are ideally presented and organized around specific domains.

Within a psycho educational context, relevant domain might revolve around

• cognitive ability
• level of achievement
• presence of a learning disability
• learning style

In contrast, a report written to assess personality/psychopathology might focus more on areas such
as

• coping style
• level of emotional functioning
• suicide potential
• characteristics relevant to psychotherapeutic intervention
• diagnosis.

Deciding What to Include

Deciding what to include is largely determined by the referral source.

Raw Data and Quantitative Scores

Generally raw data and quantitative scores should be avoided in the impressions/interpretations
section of the report.

Client Feedback

One of the crucial roles of a psychological report is to assist in providing client feedback.

Such feedback is expected to be clear, accurate, direct, and understandable. This means the results
need to be phrased in everyday language rather than formal psychological terminology.
Models of Psychological Reports

1. the Hypothesis-Oriented Model

2. the Domain-Oriented Model
3. the Test Model

With a Hypothesis-Oriented Model, the focus is primarily on answering specific questions asked by
the referral source. For example, with a referral question like “Does Shyam have brain damage?” all
the interpretations based on the test data are directed toward answering whether this hypothesis is
supported or not

Domain-Oriented model, on the other hand, discuss patients in relation to specific topics, that is,
cognitive abilities, interpersonal relationships, personality functioning. Basically, in this model results
are grouped according to the client’s abilities or functional domains. This approach is comprehensive
and indicates a patient’s strengths and weaknesses.

The third approach is the test-oriented model. Here findings are organized around the tests
administered.

Level of Reports

Three levels of reports are there

A “Level One” report is the copied-out-or-the-manual level. The interpretive data come directly from
the manual and usually follow the format…. “People with similar profiles tent to…”

There is often little or no effort to personalize the evaluation or to differentiate which of the
interpretive hypotheses are (or are not) consistent with the history and mental status exam.

A “Level Two” report represents the minimum level of conceptual input which should be used for
most purposes. Of all the possible interpretive hypotheses generated by the test, the only ones
included in the “Results of Evolution” 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.

• describe the nature of the problem and how it developed overtime

• 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

Format for psychological Reports

Following listing provides an outline of typical areas

• name
• age (date of birth)
 • sex
• ethnicity
• date of report
• name of examiner:

I. Referred by – Referral question

II. Evaluation procedures
III. Behavioral observation
IV. Background information
V. Tat results
VI. Impressions and interpretations
VII. Summary and recommendations

Referral Question

The Referral Question section of the report provides a brief description of the client and a statement
of the general reason for conducting the evaluation.

This section should begin with a brief, orienting sentence that includes essential information about
the client.

a prerequisite for this section is that the clinician has developed an adequate clarification of th
referral question.

The advantage of listing all referral questions is to allow easy reference to them at the end of the
report, in the summary and recommendations sections.

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.

For legal evaluations or other occasions for which precise details of administration are essential, it is
important to include the date on which different tests were administered and the length of time
required to complete each one.

Evaluation procedure may not necessarily be restricted to testing and interviews with the client.

This section might end with a statement summarizing the total time required for the evaluation.

Behavioral Observations

Behavioral observations are a critical component of every report.

The behavioral observation section will usually include a brief description of physical appearance,
client comments and reactions to the process, responses to different assessment activities, unusual
mannerisms or behaviors, variations in activities, and changes in voice tone and facial expressions.
Background Information

This section is critical for many readers because it provides a context in which to interpret the
assessment results. The background information portion of the report should provide the reader
with an overview of relevant information regarding the client.

The information in this section may come from interviews with the clients; interviews with other
family meanders (e.g., parents if the client is a minor); or past educational, counselling, or health
record.

For adult clients, this section should include a description of the current employment situation and
any other past or present work-related information germane to the assessment.

Test Results

The Test Results section summarizes the actual scores the client received.

Impressions and interpretations

This is the heart of the psychological report and will be the longest section.

The focus should be on the pertinent findings and interpreting rather than simply reporting the
findings. The report should include sufficient detail so that a reader unfamiliar with the specifics of
the instrument can understand the meaning of the results.

Furthermore, there should be a discussion of both consistent and inconsistent scores and results.

When a diagnosis is presented in a report, there should be sufficient evidence to support that
diagnosis. A summary is not needed at the end of the results and interpretation section because one
will be provided later in the report.

Summary and Recommendations

The value of a psychological report rests in large part, on the summary and recommendations
generated by the evaluation

The purpose of the summary subsection is to rest state briefly the primary findings and conclusions
of the report

A useful strategy in the summary section is to provide brief Bulleted /numbered answers to each of
the referral questions

The ultimate practical purpose of the report is contained in the recommendations because they
suggest what steps can be taken to solve problems

Recommendations need to take into account the patients stregths, interstes, and resourcesas well as
the problems unonvered by the evaluation

The best reports are those that helps the referral sources and or the clients solve the problems they
are facing

In conclusion or thorough psychological report written by a well trained clinician can provide a wealth
of information that can be used in treatment planning .
councillors who write psychological reports should ensure that the writing is clear and concise and
that it accurately describes and interprets the clients assessment result