Report (General)

Introduction

The psychological report presents an opportunity for the professional psychologist to present the results of assessment in a case-focused, problem-solving manner. Its major purpose is to help the referral source make decisions related to the client. It thus represents the end product of assessment. An ideal report will be written according to general guidelines and in a flexible but predictable format.

The most frequent categories of reports are centred around questions related to intelligence/achievement, personality/psychopathology, and neuropsychology areas (Camara et al., 2000). Additional, less frequent categories include adaptive/functional, developmental, neurobehavioural, aphasia, and behavioural medicine/rehabilitation. The most frequent general issues relate to diagnosis and answering which type of treatment would be most effective for a given client. Each of the various categories of assessment require different types of [Page 813]assessment instruments, knowledge related to the type of difficulty, awareness of the context (educational, legal, medical, rehabilitation, forensic), and knowledge of the various resources available in the community. This knowledge will then be integrated into the report in order to make it more problem focused and relevant to the referral source.

General Guidelines

The length of the report varies considerably across various referral settings. Traditionally, psychological reports have been between four and seven single-spaced pages. In medical contexts where time efficiency is crucial, psychological reports rarely exceed two pages. However, psychological reports in a wider number of contexts also appear to be getting shorter due to the cost containment and time efficiency demands of managed healthcare. In contrast, legal contexts demand far more detail, require greater accountability, typically have more complex referral questions, and involve more flexible, ample methods of reimbursement. As a result, reports tend to be 7–10 pages and sometimes even longer. Reports are therefore influenced by and formatted according to the conventions of other health professionals working within the contexts psychologists write for.

A well written report also pays particular attention to the degree of emphasis given to the various points. Sometimes, the evidence for a conclusion will be consistent, strong, and clear and this can then be stated accordingly in the report. Other information might be more speculative and should be written with an appropriate degree of tentativeness.

Test interpretations are ideally presented and organized around specific domains. The selection of which domains to include should be driven by the types of questions the referral source is requesting. These questions largely determine the types of assessment tools used and types of questions asked of the resulting data. Since each client is different and lives within a different context, the number of domains will vary considerably. Within a psychoeducational context, relevant domains might revolve around cognitive ability, level of achievement, presence of a learning disability, or learning style. In contrast, a report written to assess personality/psycho-pathology might focus more on such areas as coping style, level of emotional functioning, suicide potential, characteristics relevant to psychotherapeutic intervention, or diagnosis.

Sometimes test results are presented in a test by test fashion. This has the advantage of making it clear where the data came from. However, it runs the risk of being overly data/test oriented rather than person oriented. Research has consistently indicated that readers of reports do not feel this style is ‘user friendly’ (Tallent, 1993). In addition, it indicates a failure to integrate data from a wide number of sources and suggests that the practitioner has not adequately conceptualized the case. It also encourages a technician-oriented role rather than one in which a knowledgeable clinician integrates a wide array of information to help solve a client's problem.

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