Health and Psychology

There's a format to psychological assessment report writing.  The actual report style may vary based on the setting and the purpose of the report.  But the report is generally written for the intended reader of the report.  So if I'm writing a report for a court case, it's written for an attorney.  If I'm writing a report for a colleague on their client, it's written for the psychologist.  If I'm writing for a physician's patient, it may be written so the patient can understand it or it may be written for the physician.

Here are the basic principles of report writing.

• Include all the information about the assessment in a section at the beginning of the report.
• Patient Name
• Patient ID/Date of Birth/Case Number
  
• Date of Evaluation
• Name of Evaluator
• Type of Evaluation

• Include the reason for the referral and questions the report is designed to address
• Mr. Smith was referred for a psychological evaluation to facilitate disability determination for the Social Security Administration.  The purpose of the report is to address cognitive and emotional difficulties that may interfere with potential employment, and competency to manage funds.
  
• Robin Campbell, a 4 year old Caucasian female, was referred for an evaluation to determine eligibility for Gifted and Talented Education (GATE) classes in school.
• Bill Winters, a 32 year old African American, right handed male, with 12 years of education was referred for a neuropsychological evaluation following a traumatic brain injury that occured in July 2010.
  
• Janice Han, a 23 year old Korean female grauate student is requesting an evaluation for possible learning disorder and to provide recommendations for accommodations for school examinations and formal testing for admissions to programs.

• Provide background and history that is pertinent to the evaluation.
• This is the second psychiatric hospital admission in the past two months due to suicidal threats.
• Susan has been tried on four different antidepressant medications in the past year and continues to report symptoms of ongoing depression.
• Steve reports that he is having difficulties completing homework, paying attention in class and remembering to turn in assignments.

• Present the details in a meaningful, orderly, and functional manner. 
  
• Group related pieces of information together in a single paragraph.  For example, put all information concerning pregnancy and delivery complications, developmental history, and milestones together in a section on Birth History and Developmental Milestones.
  
•  Use separate paragraphs only if you want to emphasize a particular issue, such as the precipitating influence of job loss on the current illness.

• Use section headings to organize the material meaningfully for the reader.
• Reason for Referral
  
• Clinical History
• Review of Records
  
• Behavioral Observations
  
• Mental status Examination
• Tests Administered
• Test Results
• Conclusions
• Diagnosis
• Recommendations
  

• Use good paragraph structure.  The first sentence of the paragraph tells what the whole paragraph is about. The last sentence sums up the paragraph.  The middle sentences provide supporting evidence or points being made.

• Within each topic, follow a chronological sequence. 
  

• Keep information under the appropriate subheading.  Don't put Mental Status details or behavioral observations under Background Information, or vice versa.

• 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.

• Report information clearly and with confidence.  Avoid excessive use of words like "might be, may, reportedly; according to the patient; or the patient stated."  Once you've made it clear that the history came from clinical interview, you don't need to repeatedly qualify the data.  Excessive use of these words tell the reader that you lack confidence in your data and/or your ability to judge the reliability of the informant. One way to avoid this is to use quotation marks occasionally to let the reader know you are relating the patient's opinions.

• When reporting the results of the assessment it's important to describe the individual not the test.  Test scores or computerized printouts can be provided in an addendum to the report.  It's the job of the psychologist to clarify who the person is based on the results of the assessment.

• The more clear the writing style the better. 
  
• Little use of jargon
  
• Use of tables or charts to show data graphically
• Limiting complex sentence structures that require the reader to re-read the information to understand it

Clarity in writing is especially important when communicating to the general public and someone not familiar with professional reports.