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Block 2 Unit 4 Report Writing and Recipient of Report

1) Define and describe psychological report.

A psychological report is the end product of an assessment, where a psychologist presents results in a case-focused, problem-solving manner. The main purpose of the report is to aid the referral source in making decisions about the client. An ideal report is written using general guidelines in a flexible, yet predictable format.

2) What features are included in the psychological report? 

Features of a psychological report include:

• The reason for referral and identification of the referring party.
• A list of the assessment instruments used.
• Actual test scores.
• The psychologist’s interpretation of the scores and findings.
• A diagnostic impression.
• Recommendations.

3) Delineate the general guidelines for psychological report writing. Describe the general guidelines for a psychological report with examples.

General guidelines for writing a psychological report include:

• Length: The length varies based on the referral setting. For example, medical contexts may require short reports of no more than two pages, while legal contexts need longer reports of 7-10 pages.
• Degree of Emphasis: A report should pay particular attention to the degree of emphasis given to various points, based on the consistency of the evidence.
• Domains: The number of domains included will vary depending on the client and context. Psychoeducational contexts might focus on cognitive ability and achievement, while personality assessments may focus on coping styles and emotional functioning.
• Content: The report should avoid being overly data/test-oriented, and should be person-oriented. It should integrate data from various sources, and indicate a comprehensive conceptualisation of the case.
• Client Feedback: Reports should assist in providing client feedback, using clear, accurate, direct, and understandable language. The language should be in everyday terms rather than formal psychological terminology.

4) Discuss the importance of psychological report? 

A psychological report is important for several reasons:

• It helps the referral source make decisions related to the client.
• It presents the results of the assessment in a case-focused, problem-solving manner.
• It provides a summary of test results, interpretations, and recommendations.
• It assists in client feedback and may have therapeutic benefits.
• It can provide descriptions of relevant background information, which can be important in medical contexts
• It provides an opportunity to make person-focused recommendations

5) What are the various models of psychological report? 

There are various models for psychological reports, including:

• Test-Oriented Model: This model presents test results in a test-by-test fashion. This model runs the risk of being overly data-oriented rather than person oriented and is not considered to be very user-friendly.
• Domain-Oriented Model: This model presents data according to "functional domains" such as intellectual ability, interpersonal skills, and coping techniques. It is useful when there is no specific referral question, but may include irrelevant information.
• Hypothesis Testing Model: This model focuses on possible answers to the referral questions, presenting data to support or refute hypotheses. This model is concise but may not include all the data that could be useful to other disciplines.

6) Discuss the domain oriented model. 

The domain-oriented model organises a report around functional domains, such as intellectual ability, interpersonal skills, psychosocial stressors, coping techniques, and motivational factors. Separate paragraphs are devoted to each of these topics. This model is helpful when there's no specific referral question, as it provides a broad overview of the client's functioning. This model is also useful when the assessment is being used to monitor treatment progress. A weakness of this model is that the reader may be presented with a lot of information that has little relevance to their intended intervention.

7) Elucidate the hypothesis testing model. 

In the hypothesis-testing model, the report focuses on possible answers to the referral questions. A hypothesis is presented in the "Purpose for Evaluation" section, and data is then presented 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. The strength of this model is its efficiency and focus on the referral problem.

8) Discuss the three levels of report writing.

There are three levels of report writing:

• Level One: This is a basic report copied from the test manual and is generally conceptually weak. This level is only appropriate when there are circumstances that make it impossible to interview the patient or obtain background information, and it should be clearly stated as such.
• Level Two: This level of report includes only interpretive hypotheses confirmed by the history or clinical interview. The interpretive data does not come directly from the manual, and this is suitable for most purposes.
• Level Three: This highest level of conceptualization, integrating all available information to describe the problem, influencing factors, recent exacerbating factors and provide suggestions for intervention.

9) What is meant by referral questions? 

A referral question sets the stage for the rest of the report, making it important to ensure it is clear and specific. It clarifies the reason for the assessment. A referral question may need to be clarified through discussions with the referral source since it is common to have a poorly articulated referral question. Discussions with the referral source will assist in determining what can and cannot be answered through formal assessment, and might result in the decision that formal assessment is not appropriate.

10) Elucidate how to write evaluation procedures. 

Evaluation procedures are the methods used to gather information about the client. In this section, the psychologist should communicate that their evaluation is a professional integration of information from a variety of sources. It should list the tests and procedures used such as the mental status exam, and clinical interviews. The report should also note who gave the tests and how long it took to complete.

11) Describe behavioural observation in a psychological report. 

Behavioral observations in a psychological report involve describing the client's appearance and mannerisms, as well as any significant interactions. These descriptions should be specific and note any relevant behavioural, affective, and interactional observations. This section should also include information about the client's behaviour during testing and interviews, free-play behaviour, and interactions with parents or siblings if relevant.

12) What type of background information is included in psychological report? 

The background information section of a psychological report includes relevant details about the client's history. This section should avoid being overly inclusive and should be tailored to the client's context. This might include medical history, vocational/employment background, family background, personal history (infancy, early/middle childhood, adolescence, early/middle adulthood, late adulthood), and other areas such as fears or recurring dreams. The background information should clarify where the information came from.

13) What ways the test results are presented in a psychological report? 

Test results are presented in a psychological report by listing the tests used, with a brief description of what each test measures. The results should be reported by section, subtest, or total score. Test results are often presented in a test by test fashion. This can help make it clear where the data came from, but can also run the risk of being overly data/test oriented rather than person oriented. The way test results are presented should be understandable to a non psychologist.

14) Why is impressions and interpretations are important in a report? 

Impressions and interpretations form the main body of the report, integrating findings based on test scores, behavioural observations, relevant history, records, and other available data. The information is presented according to domains rather than test by test. The selection of domains is based on answering the referral question. If ability/IQ measures are included, these are traditionally placed first as they often provide context for understanding other information.

15) What would contain in the summary and recommendations?

The summary and recommendations section should answer questions that were posed in the purpose for evaluation section and present a conceptualisation of the case. DSM diagnostic impressions may be included with detail from the report provided to support the diagnostic criteria as described in DSM. This section provides an opportunity to offer person-focused suggestions for solving specific problems. The recommendations should be highly specific rather than general.

16) Describe the format for psychological report by using suitable examples? 

A sample format for a psychological report would include:

• Identifying information, such as the client’s name, case number, admission date, date of evaluation, date of report, and facility name.
• Purpose for Evaluation: This section introduces the client and the problem and poses a question that will be answered in the summary. This section may also include preliminary test results.
• Assessment Procedures: This section describes the tests and procedures used in the evaluation.
• Results of Evaluation: This section addresses conceptual issues by integrating data from various sources to support or refute the hypothesis presented in the "Purpose for Evaluation" section.
• Summary/Recommendations: This section answers the question posed in the "Purpose for Evaluation" section and includes recommendations for treatment.
• A statement indicating that the report is confidential.
• The signature, name, and title of the author.

Important Points

1. The psychological report is the end product of assessment.

2. A report for a mental health professional may be very different from one written for a school teacher or a parent. Most psychologists avoid professional jargon so that their reports will be understandable to non-psychologists.

3. The length of the report varies considerably across various referral settings. For example, in medical contexts, psychological reports rarely exceed two pages, while in legal contexts, reports tend to be 7-10 pages or longer.

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

5. The referral question sets the stage for the rest of the report.

6. The main body of the report is contained in the impressions and interpretations section and summary and recommendations section.

7. The summary and recommendations section of the report provides an opportunity for the practitioner to succinctly state the main conclusions of the report.