At some point in our lives we are likely to have to make or receive some kind of report, either at a personal or work level. Whether it is to analyse the state of an entity, object or specific situation or its evolution over time, or to justify a particular action or the need for it or to assess the presence of changes from this, in many cases we will have to give an account of them to inform others of our activity or what has happened.
The field of psychology is no exception, especially in the clinic: we must write a report of each patient or client we have in which we detail their data, problems, results of evaluations, treatments or interventions applied and results. But writing a report correctly may not be as simple as it seems. In this article we are going to look at a series of steps to answer the question of how to write a psychological report .
11 steps to writing a psychological report
Writing a report in a clinical setting may seem easy, but it must reflect the whole element, person or situation to be analysed in a way that is understandable. Below are a number of steps to consider in order to do it correctly. Focusing on the psychological report and especially on the clinical one .
1. Be clear about the type of report you are doing, what it is for, and about what/who you are doing it about
Although it may seem obvious, the first step in producing a report correctly is to know what we are doing it for, the type of report and the data we are going to reflect in it. This will allow the information to be structured in one way or another and to clearly reflect the most relevant data for the case.
2. Informed consent
An important preliminary step in the drafting of a report, at least when it is made in respect of a person, is the consent of that person. It must be reflected in the report that the person is aware that data is being collected from him/her for a specific purpose, and his/her signature and/or agreement is required for this. This consent is usually reflected in the final part of the psychological report.
3. Collect and structure the information
A report does not start from nothing: it is necessary first of all to collect the data of the subject or situation to be analysed or described , paying attention to as many details as possible.
The information we write down will be used later to write the report. We must also be clear about the structure of the report, which will vary according to its objective. The following four steps refer, in fact, to the structure in question.
4. First the basic data
To write a report we will need, as we have said, a great deal of data, which in order to be comprehensible we will need structures in various areas. In a psychological report we will first take into account the basic demographic data of the patient or client, who is requesting the report and/or the objective of the report, a brief description of what is happening to him/her and what makes him/her come to us, the data of the centre and professional who is attending or doing the report.
5. The case evaluation process: evidence and results
After the most basic data, it is necessary to go into detail by first stating the information taken from the initial assessment. Each of the tests and interventions carried out should be recorded, and a justification of why these were chosen can be added .
The results obtained from this evaluation (including the diagnosis if any) will be reflected below, showing the specific data obtained. This information can be divided into several sub-sections (e.g. intellectual capacity, personality, socialization, etc.), but should allow an integrated picture of the case in question to be formed. In the case of clinical practice we have to take into account not only the current problem to be treated but also the background, consequences of the problem, modulating variables that may interfere with or maintain a problem and how all these factors relate to each other.
6. Reflects the objectives and the proposal for intervention
After the assessment of the case, it should be reflected whether any action or intervention has been made. If we are dealing with a psychological report, it is necessary to reflect the objectives to be achieved with a possible intervention, negotiated with the patient or client. In another section the intervention plan followed during the case will be detailed .
7. Results and follow-up of the intervention
The report should record the different practices and actions carried out by the issuer, as well as the results of such intervention. It should also record any changes that have had to be made.
It is very important to reflect the evolution of the subject or situation, as well as the tests and methods of psychological evaluation that could have been carried out in order to assess it in the case of applying it. It will be assessed whether or not the treatment has been effective and whether there is a need to follow it or modify it. Also if the patient is discharged or if a referral is made.
8. Must be understandable and useful for the reader
When writing a report, it is essential to bear in mind that it is done so that other people or the same professional at different times can understand what has happened and been done throughout the process being reflected. The target audience must be taken into account: it is not the same to write a report full of technicalities that only another professional in the sector can understand as to prepare it for, for example, handing it over or returning it to the patient/client.
We must use clear and concise language that is appropriate and understandable to the objective reader of the report.
9. Be objective
A psychological report should contain contrasting data , which another person could replicate through the same procedures carried out. Thus, one should start from the client’s reflection and the tests carried out and not transcribe personal opinions or inferences. The results of the report should be replicable by other professionals if the same methods are used.
Similarly, the inclusion of value judgments (both negative and positive) that contaminate the data or the attitude of the reader of the report (whether it is the subject himself, another professional or the patient/client) towards the case should be avoided.
10. Reflects the essential
When writing a report we have to take into account that it is a text in which we will summarize the data we obtain : it is not a complete transcription of each interaction carried out.
We must focus on the most relevant aspects, not reflecting unnecessary information but only the elements that are necessary to evaluate the case and its evolution.
11. Prepare the return of the report
While the writing of the report may have been completed, it is very important to consider not only the data but how it will be reflected or expressed. It is possible that the client or patient may not request the report in writing , but it should always be returned at least orally. This is of great importance as it can have a direct effect on the patient or client.
How it is explained can be as important as, or even more important than, what is explained: it is not the same, for example, to let someone with a disorder out of the blue as it is to explain it in an understandable way, tactfully and without stigmatization . Space should also be left for the subject to express doubts, so that they can be resolved.
It should be noted that the report is delivered completed, whether it is because the incident, problem or disorder in question has been resolved or a referral is made to another professional who will continue to work on the case.