Notes From an Inservice on Psychological Report Writing

The following notes include a variety of suggestions and comments

concerning effective communication of the results from a
psychological evaluation. Comments are welcome.

PSYCHOLOGICAL REPORT WRITING TIPS

Inservice by Greg Nail
Mississippi State Hospital
December 6, 1990
(includes subsequent revisions)

1. There is no one "correct" way to write a report. It needs to be unique to the

writer and the patient. Styles often change with each report written. However,
there are some basic guidelines that will help to write reports (regardless of
style issues) clearly and meaningfully.

2. Purposes for the report can vary, they include:

 Answer specific questions

 Treatment planning
 Formulate/conceptualize the case
 Monitor progress
 Provide diagnostic input
 Assess therapy outcome
 Facilitate prognostications

3. Tailor the report to the reader with respect to his training, his familiarity with
terms, uses for the report, and what questions he is asking. Address the
referral question. If the question is inappropriate or can not be answered with
psychological assessment, you may need to consult with the referral source
and modify the question. Don't just copy the question from the referral
sheet. Use this section of the report to state the "Purpose of the
evaluation." Word the referral question to cue the reader as to what
confirming/refuting data to focus on while reading the report. Tell him what
case you are building. (e.g., let him know to cue in on the Avoidant Personality
issues.) You don't want him to get to the end of your report, then have to read
it again to see if your conclusions were supported. Let him be forming this
judgement while he reads.

The referral question can help the reader get a better understanding of what
psychological assessment can potentially provide. Address unwritten needs of
referral source, such as objective confirmation of diagnosis, presence/absence
 of risk factors for aggression, suicide, etc.

4. Standardized Format for Psychological Reports- everybody has his own

preferences, making it difficult to agree on a standard format. However, the
advantage of consistency in the format is that you know where to look for
specific details when reading other people's reports. Developing a consistent
format also helps you avoid omitting info and speeds up report writing. You
don't have to re-invent the wheel for each report. Just modify its design a
little!

5. Improve report writing with good structure. The goal of the report is to reach a
logical conclusion that answers the referral question(s) and is supported by
valid, reliable data. Use the body of the report to establish credibility for your
conclusions. You have 3 sources of data:

/ BEHAVIORAL OBSERVATIONS \
CLINICAL HISTORY \ MENTAL STATUS EXAM / TEST DATA
\ | /
\ | /
\ | /
\ | /
\ | /

CONCLUSIONS

If any one of these is missing (e.g., test data), you still have two sources of data for the
report!

6. Have a plan or general outline in mind when you start writing. Know where
you're going; what conclusions you're building toward. If you start writing
with the idea that you'll figure out some conclusions when you get to the end
of the report, you'll need to do extensive rewriting to make the report flow
smoothly and to remove the unnecessary details.

7. Within this framework you want the report to flow smoothly, so that minimal
effort is required of the reader to organize the data. Help him assimilate the
information by giving him an efficient structure. Let him concentrate on
understanding the patient, rather than being distracted by trying to "put the
pieces together."

 in the Referral Question you told him what information to look for in
the report

 now give him a "gestalt", a framework on which to place all the details
you are about to present. Do this with a concise demographic
description at the beginning of the Background Information section.
 Let him get a mental image of the patient you are describing. (e.g., This
is the first MSH admission for this 36 year old, single, white female
who has 13 years of formal education and is employed as a sales clerk.)

8. 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 family, friends, marriages,
interpersonal conflicts, etc., in a single paragraph dealing with social
issues. Use separate paragraphs only if you want to emphasize a
particular issue, such as the precipitating influence of marital conflict
on the current illness...or retardation in the development of coping
skills due to abuse during childhood.

 Use good paragraph structure. The first sentence of the paragraph tells
what the whole paragraph is about. The last sentence sums up the
paragraph.

 Within each topic, follow a chronological development. You don't

want the reader to have to stop and figure out which admission came
first or which symptoms appeared last, etc.

 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 "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.

 Qualifiers are important at times, but excessive use reveals indecision

or uncertainty. Avoid excess use of "appears to, suggests, may be,
apparently, etc". Rather, say "The patient is..." Use of behavioral
descriptors can help here. For example...
 (WEAK) (BETTER)

The patient may have conflicts The patient's difficulty with authority figures
dealing with authority figures. is evident in his multiple expulsions from
school, arrests, and frequent loss of jobs due
to "personality conflicts" with employers.

 Include only details that are relevant to your conclusions. Excess

details distract the reader from the case you are building in support of
your conclusions. For chronic schizophrenia you might spend several
paragraphs on past treatment efforts and only a sentence or two on
family issues. For an avoidant personality disorder, you might spend
several paragraphs on family and other interpersonal issues, while
devoting only a couple of sentences to prior treatment. Remember, the
purpose of the psychological report is usually NOT to provide a
comprehensive social or medical history. Include only relevant details.

 Generally, don't repeat information. If paragraph one stated that the

patient has been repeatedly fired from jobs, don't repeat this in
paragraph four as part of the "social issues" paragraph. Find a way to
convey all the information and only say it once. Exceptions to this rule
include repetition for emphasis and limited repetition in the summary.

9. Diagnose, conceptualize, or both? Opinions differ as to whether the report

should emphasize formal DSM diagnosis or focus on an effort to conceptualize
the case (i.e., present a systematic description of the individual, his problem,
how the problem developed, and the forces which maintain the problem). In
my humble opinion...

 DSM categories do a poor job of helping therapists understand

individuals

 Psychological tests are poor predictors of DSM labels. (However, the

combination of test data and clinical inference does improve the
reliability of DSM diagnoses)

 Psychological evaluation is used most effectively when the emphasis is

on conceptualizing the case, rather than generating a DSM diagnosis.

 It is appropriate to include a DSM diagnosis, so long as you also

provide a "paragraph style" conceptualization of the case. Don't just
label the person. Go beyond DSM and help your reader understand the
individual.
  The uniqueness of psychology centers around our theories and efforts
to make sense out of the distorted clinical picture. For example...

(WEAK) (BETTER)

Results of this evaluation Results of this evaluation reveal the presence

reveal the presence of
an avoidant personality
disorder.
of an Avoidant Personality Disorder, as
evidenced by (list the relevant DSM criteria).
This patient displays a chronic inability to
establish and maintain satisfactory interpersonal
relationships (or to maintain employment). He is
relatively anxious individual who experiences
marked internal conflicts over dependency
issues. He has intense, unmet needs for
attention and affection. However, his
emotionally abusive childhood has led to
extreme fear of rejection or humiliation in
interpersonal relationships. His cool, detached
public presentation represents a defensive effort
to shield himself from emotional pain.

10. The TEST RESULTS section is more appropriately titled RESULTS OF

ASSESSMENT. In this section you want to do more than just copy the
interpretive hypotheses out of the manual or from the computer printout.
Describe the individual, not the tests. In general there is no need to mention
specific tests by name (IQ tests are an exception). Rather, present those
portions of the test data which you can confirm during the diagnostic
interview, from collateral reports, or from review of records.

Statements such as "Individuals who obtain similar profiles.." or "These

patients tend to..." suggest that you are unsure whether or not the data fit this
specific patient. The report is more individualized when it reads like.... "Mr.
Jones prefers to (describe the relevant trait) as is evident in (some specific
thing he has said or done)".

11. Where inconsistencies exist between tests (e.g., MMPI-2 vs MCMI-III) try to
figure out WHY there is a discrepancy.

12. If the patient is too psychotic, disorganized, or uncooperative to be evaluated,

then be specific about why you were unable to complete the evaluation and
what efforts you took to try to motivate cooperation. Be sure your reader
understands that you put forth appropriate effort. Even in cases like this, you
can still write a report. Your description of the type of uncooperativeness
encountered is important (e.g., Repeated efforts to conduct psychological
evaluation were unsuccessful. The patient refused to answer most questions
 and became hostile when encouraged to participate. Efforts to establish
rapport were impaired by extreme paranoid ideation exhibited during the
sessions.)

13. Stating that a patient is psychotic tells little about the problem. Be specific...
(e.g., Results of psychological evaluation reveal the presence of a psychotic
thought disorder characterized by disturbed thought process with relative
integrity of thought content, and no clear indication of ongoing perceptual
disturbance.

 Distinguish between disturbance of thought content vs. disturbance of

thought process.

 When hallucinations are present, be specific about the type (auditory,

visual, tactile) and about their content.

 Be specific about the content of delusions and note whether they are
systematized.

 If there is a disturbance of thought process (i.e., formal thought

disorder) be specific about what is abnormal. Thought process can be
described as "intact and goal oriented; well organized; significant for
marked loosening of associations; tangential; circumstantial; etc)

 Address both the "range" and "appropriateness" components of

affect. Range refers to fluctuations in affective presentation and can be
described as normal, restricted, blunted, etc. Appropriateness refers to
the consistency between what the patient says versus his facial
expression and tone of voice.

 State which "negative symptoms" of psychosis are present. These

include impoverishment of emotional expression, reactivity, or feeling;
impoverished thinking or cognition; disturbance of thought process;
poor grooming; impersistence at work; physical inertia; general lack of
energy,drive or interest; decreased pleasure in recreation, sex, or
intimacy.

14. Avoid using jargon or terms for which there is little consensus as to their
meaning. State what you observe rather than just saying ....impaired "reality
testing", or that the patient appeared "characterological", "neurotic", or that he
displayed "cognitive slippage", or "perceptual insensitivity."

15. Avoid vague comments that don't really describe the patient or changes in his
status. For example...Rather than saying the patient "improved" on Haldol,
state what changes were observed that suggested improvement. Were there
 specific changes in mental status, self care,...etc.?

16. Be sure to use the terms reliability and validity correctly. Misusing these
terms is the psychological equivalent to saying "ain't" in English class and is
second only to, "The data is.." when it comes to destroying your credibility in
the eyes of other psychologists.

17. There is no such thing as an "invalid" MMPI. You can always gather
inferences from the data, even if it's only an explanation of why the F scale
was so high and all the clinical scales are so elevated. In general, you can
avoid confusion by not specifically mentioning the "validity" of the
MMPI. However, if the validity issue is addressed in the report, an appropriate
option might be to say something like... "Results obtained on the MMPI-2
were psychometrically invalid. However, the resulting clinical profile was
partially consistent with the client's history and clinical presentation in
that...." An even more attractive option would be to avoid using the term
validity, and just address the specific reliability/validity points that tend to be
(inappropriately) lumped together under this heading. For example: "The
client responded to objective testing with excessive endorsement of
pathological items, suggesting a deliberate effort to present himself in a
negative manner. He scored particularly low on scales addressing
psychological defensiveness and tended to endorse obvious indicators of
psychopathology much more frequently than relatively subtle indicators of
similar problems. Furthermore, he failed to provide consistent answers to
similarly worded test times, possibly suggesting inattentiveness to the task.)

18. When referring to yourself in a report there is no clear consensus whether you
should use personal pronouns or refer to yourself as "the examiner." Many
psychologists feel that referring to yourself in the third person makes the report
sound more objective and formal. Others (including myself) feel that it makes
the report sound awkward and stilted. One option is to find ways to avoid
references to yourself. For example,

(WEAK) (BETTER)

The patient was angry with The patient voiced frustration and
me for interrupting his hostility over disruption of
scheduled activities on scheduled ward activities.
the ward.

19. It is sometimes appropriate to do a relatively cursory assessment in order to

give rapid feedback to the referral source. This is often the case on receiving
units where the patient may provide an unreliable history and access to
medical records or family members is delayed. In these cases I recommend
including "qualifiers" in the report in order to let the reader know that
 additional useful information is potentially available from psychological
assessment. They also cue the reader that the data have not necessarily been
verified. For example,...

Under Purpose of Evaluation...rather than saying the patient was referred for
psychological evaluation, you could say that he was referred for "psychometric
screening".

In the Summary.....rather than saying "Results of psychological evaluation

indicate..." you might say "Results of psychometric screening suggest..."

The last sentence of the summary could read.. "These results of psychometric
screening should be viewed as tentative, until confirmed by further clinical
data."

20. Rather than having a section called "Tests Administered", I recommend calling
it "Assessment Procedures." Under this section you can then list "Clinical
Interview" and "Mental Status Examination" along with the tests. This helps
communicate to the reader that your evaluation is an integrated evaluation, not
just a list of test results. In this section you might also list "Review of Prior
Psychological Assessment Dated ------", "Interview With Joe Blow (patient's
brother)", "Review of Medical Records."

21. Try to vary your sentence structure, throwing in some dependent clauses. This
will make the report more readable. However, it's best not to get so "flowery"
that its hard to understand. You don't want the reader to have to reread a
sentence to figure out what you are talking about.

(WEAK) (BETTER)

Never having attained gain- Despite his superior intellectual

ful employment, the patient, ability, the patient's excessive
a precocious, intellectually resentment for authority figures
gifted, young man who and external demands has led to
dropped out of school after chronic impairment of academic
fifth grade owing to personality and vocational success.
conflicts with his geography
teacher, a demanding, overly
critical authority figure, is
excessively resentful of
external demands.