Psychological Report Writing
Summary
- ties it all together and communicated what you think of all this. No longer "AG reported..." this is your conceptualization - one or two statements or ideas from each of the sections - needs to be concise and accurate so reader can quickly find the essential information... - start broad, and become increasingly more narrow/specific in your discussion
Categories to Observe
- Appearance (quick note is looking good e.g., "things were within normal limits", definitely comment if looking disheveled) - nonverbal communication - interaction style with examiner - attitudes toward test situation, examiner, self - affect/mood - language and thought patterns - response to tasks - implications for validity/representativeness - speak to where information is coming from (where information is provided by)
Preliminary Components of the Report
- Identifying information - Referral question - Techniques/Materials used - Background Information - Behavioral Observations
Problems of interpretation
- irresponsible interpretation (based on idiosyncratic)
Most Importnat Determinants
- The needs of the client - The nature of the problem facing the client - The report should be person-focused - Theory, technique, and style are in the service of meeting the client's needs
Identifying Information
- The patient or client and the examiner must be identified clearly - When and where - Format for the material, listed or in narrative form, depends
Recommendations
- careful, specific recommendations that will assist the referral source in dealing with this particular client - be aware of the range of interventions available for a particular problem area - consider likely outcomes of recommended outcomes
Response to referral question
- direct response to referral question is mandatory - give as many recommendations that are relevant to referral question - may include diagnosis, but a detailed description of the client may be more useful - diagnostic impressions - prognosis/prediction is one of the most difficult questions to answer
Other specific things to address (2)
- do not copy and paste
Problems with attitude and/or orientation
- find a balance with authoritative
Quick definitions
- impairments = relative to normative population (borderline range, average -- between subjects - deficit = relative to one's own previous performance -- within subjects (some significant incident in life TBI) - strengths and weaknesses = relative to one's own performance on other subtests in the current evaluation
Results format for this Course
- index name as subheading (VCI) - description of the index and scores obtained - table listing SS, Percentile, classification of each subtest - briefly describe relationship among subtests. Describe any subtest that represents a strength or weakness (what's important about that table - do not need to explain every single subtest, just the important ones and what the relationship was like among scores, in a few sentences (e.g., large discrepancy between two or three subtests within an index)
Summary and Recommendation
- may be the only part read - well... (what did you find) - very clear and helpful - gives a snapshot - repeat highlights of each section of report in summary form not just stating the same thing -- functioning -- strengths -- problems all within context of referral question, tie it all together - provide specific recommendation for referral party within specific context
Problems of context
- never going to include raw data - inclusion/omission of diagnosis, prognosis, recommendations - improper emphasis (not geared toward referral question) even if something is interesting (might discuss with person, but will not base report on that type of information
Behavioral Observations (2)
- no need to include typical, expected behavior - behavior that is unexpected, out of the ordinary, and unique to this particular client -
Results and Interpretation
- order of presentation depends on focus of report and nature of data collected - degree of detail depends upon audience (client needs to be able to read it) - scores, if needed, can go in technical addendum (go in tables, breaking things out into tables, starting broad, then breaking it down) - technical language puts focus on tests - interpretation at this stage may be limited to what is typical of individuals obtaining similar results
Body of Report
- preceding sections (earlier sections) set the stage, give context of particular person - body of report communicates person in context - *with reference to referral question* - section heading can vary with purpose - contains results and interpretation - integration with relevant data - summary and recommendations
Background Information (1)
- provide a narrative of relevant background information and history on the client - stay within the context of what is important to know - provide context and meaning to behaviors - information comes primarily from clinical interview and client records (e.g., doing testing because TBI) - report is unhelpful without frame of reference for what this individual is all about
Other specific things to address (1)
- reporting FSIQ or not? - reporting GAI or not? *do not need to report both* - describing all subtests versus those worth describing *do not need to report all* - proof-read for consistency of spacing, alignment, tables, floating headers, correct pronouns and NAMES - qualitative descriptions (give one versus giving a range, pick the *one* that is appropriate--average, not low average to average) - attention vs. attentional (use attention is okay) - do not use conjunctions - APA format!!!!!
Problems with reports
- some reports are unhelpful - what to clearly convey information (style) - preferences of referring parties - limitations of psychology
Integration with other Data
- the report is most relevant when it focuses on the uniqueness of the particular client - integration of test finding with life history and current situation presents a more complete picture of the client - facilitates conclusion regard hypothese - thinking about how to give evidence to hypotheses -
Problems of Communication
- word usage, vagueness, lack of clarity, ambiguity, style of orgination
Behavioral Observations (1)
1.) During interview and test administration, be alert for any behavior that might be relevant to: - the validity of the test results - to the referral question 2.) record as specific behavior (general behavioral observations provide examples so someone knows what you're talking about) - AG frequently appeared distracted during test administration - so someone can understand the story better
Summary (2)
1.) briefly summarize/restate - referral question - specific problems/symptoms noted in history - 2.) summary test results and relevant strengths/weaknesses in organized way. describe indices in a way that makes sense to you and the reader 3.) differentiate between impairments...
Summary Cont.
1.) note any other facts potentially impacting performance other than intellectual functioning - sensory limitations (visual, hearing) - motor limitation - quality of previous education - home environment/stressors - interest pattern, effort, etc. - mental heath diagnoses if relevant
Referral Question
original nature of referral needs to be really clear, make sure sentences make sense, why you're doing it and what the question is - guide for what you're looking for - sets context for the interpretations and recommendations - important for anyone receiving the report and other refer to it in the future - keep succinct