How To Correctly Write A Psychological Report, In 11 Steps
At some point throughout our lives it is likely that we will have to prepare or receive some type of report, whether on a personal or work level. Whether it is to analyze the state of a specific entity, object or situation or its evolution over time, or to justify a specific action or the need for it or to assess the presence of changes based on it, in many cases we will have We must report them to inform other people of our activity or what has happened.
The field of psychology is no exception, especially in the clinic: we must write a report for 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 easy as it seems. In this article we are going to observe a series of steps to answer the question of how to make a psychological report
Writing a report in the clinical setting may seem easy, but it must be taken into account that it must reflect the entire element, person or situation to be analyzed in a way that is understandable. Below are a series of steps to take into account to do it correctly. Focusing on the psychological report and especially the clinical one
1. Be clear about the type of report you are making, why and about what/who you are doing it.
Although it may seem obvious, the first step to carry out a report correctly is to know why we are carrying it out, the type of report and the data that we are going to reflect in it. This will allow the information to be structured in a certain way or another and to clearly reflect the most relevant data for the case.
An important preliminary step for writing a report, at least when it is done with respect to a person, is their consent. It must be reflected in the report that the person is aware that data is being collected from them for a specific purpose, requiring your signature and/or agreement to do so. This consent is usually reflected in the final part of the psychological report.
3. Gather and structure information
A report does not start from nothing: it is necessary in the first place collect data on the subject or situation to analyze or describe paying attention to as many details as possible.
The information that we write down will later help us to write the report. Likewise, you must be clear about the structure that the report will follow, which will vary depending on the objective it has. The following four steps refer, in fact, to the structure in question.
4. Basic data first
To write a report, as we have said, we will need a large amount of data, which in order for it to be understandable we will need to structure it in various areas. In a psychological report, the basic demographic data of the patient or client, who requests the report and/or its objective, will be taken into account first. a brief description of what is happening and what makes you come to us, the data of the center and professional who is attending or preparing the report.
5. The case evaluation process: evidence and results
After the most basic data, it is necessary to go into detail, first stating the information extracted from the initial evaluation. Each of the tests and interventions carried out must be recorded, and may add a justification of why those in question have been chosen
The results obtained from said evaluation will be reflected below (including the diagnosis if any), showing the specific data obtained. This information can be divided into several subsections (for example intellectual capacity, personality, socialization, etc.), but they must allow an integrated image of the case in question to be formed. In the case of clinical practice we must take into account not only the current problem to be treated but also antecedents, consequences of the problem, modulating variables that can interfere with or maintain a problem and how all these factors relate to each other.
6. Reflects the objectives and intervention proposal
After the evaluation of the case, it should be reflected if any type of action or intervention has been carried out. If we are dealing with a psychological report, it is necessary that it reflects the objectives that are intended to be achieved with a possible intervention, negotiated with the patient or client. In another section The intervention plan that has been followed during the case will be detailed
7. Results and monitoring of the intervention
The report must include the different practices and actions carried out by the person issuing it, as well as the results of said intervention. Possible changes that have had to be made must also be recorded.
It is very important to reflect the evolution of the subject or situation, as well as the tests and psychological evaluation methods that could have been carried out to evaluate it if applied. It will be assessed whether or not the treatment has been effective and whether there is a need to continue or modify it. Also if you are discharged, or if a referral occurs.
8. It must be understandable and useful for the reader
When writing a report, it is essential to keep in mind that it is done so that other people or the same professional at different moments in time can understand what happened and was carried out throughout the process that is being reflected. The target audience must be taken into account: preparing a report full of technicalities that only another professional in the sector can understand is not the same as preparing it to, for example, deliver it or give a feedback to the patient/client about what happened.
We must use clear and concise language that is appropriate and understandable for the target reader of the report.
9. Be objective
In a psychological report verified data must appear, that another person could replicate through the same procedures carried out. Thus, it should be based on what the client reflects and the tests carried out and not transcribe personal opinions or inferences. The results of the report should be replicable by other professionals using the same methods.
Likewise, the inclusion of value judgments (both negative and positive) that contaminate the data or the attitude of whoever reads the report (be it the subject who writes it, another professional or the patient/client) regarding the case should be avoided. .
10. Reflect the essential
When writing a report we must take into account that it is a text in which we are going to summarize the data we obtain: This 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
Although the writing of the report may have been completed, it is very important to take into account not only the data but how it will be reflected or expressed. The client or patient may not request the written report, but there should always be at least an oral return of this. And this return is of great importance, since it can have a direct effect on the patient or client.
How it is explained can be as important or more important than what is explained: it is not the same, for example, to tell someone point blank that they suffer from a disorder than if it is explained in an understandable way, tactfully and without generating stigmatization Space must also be left for the subject to express doubts, so that they can be resolved.
It must be taken into account that the report is delivered finished, whether it is because the incident, problem or disorder in question has been resolved or if a referral is made to another professional who continues working on the case.
