How to write a psychological report correctly, in 11 steps

In order to prepare this type of clinical document, a structure must be followed.

At some point in our lives it is likely that we will have to prepare or receive some kind of report, either at 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 particular action or the need for it, or to assess the presence of changes from it, 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 will have to write a report on 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 will look at a series of steps to answer the question of how to write a psychological report.

11 steps to write a psychological report

Writing a report in the clinical setting may seem easy, but it must be kept in mind that it must reflect the totality of the element, person or situation to be analyzed in a way that is understandable. Below are a series of steps to be taken into account in order to do it correctly. Focusing on the psychological report and especially on the clinical report.

1. Be clear about the type of report you are making, for what purpose and about whom/what you are doing it.

Although it may seem obvious, the first step to make 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 us to structure the information in one way or another and to clearly reflect the most relevant data for the case.

2. Informed consent

An important previous step for the writing of a report, at least when it is made with respect to a person, is the consent of this one. It must be reflected in the report that the person is aware that data are being collected from him/her for a specific purpose, and that his/her consent is for a specific purpose, and his or her signature and/or agreement is necessary for this purpose. This consent is usually reflected in the final part of the psychological report.

3. Gather and structure the information

A report does not start from nothing: it is necessary to first of all collect data on the subject or situation to be analyzed or described, paying attention to as many details as possible.paying attention to as many details as possible.

The information that we write down will be used later to write the report. It is also important to be clear about the structure of the report, which will vary according to its objective. The following four steps are, in fact, related to the structure in question.

4. First the basic data

To write a report we will need, as we have said, a large amount of data, which we will have to structure in different areas in order to make them comprehensible. In a psychological report we will first of all take into account the basic demographic data of the patient or client, who is requesting the report and/or the purpose of the report, a brief description of what is happening to him/her and why you have come to us, the data of the center and professional who is attending or making the report.

5. The process of case evaluation: tests and results

After the most basic data, it is necessary to go into detail, stating first of all the information extracted from the initial evaluation. Each of the tests and interventions to be carried out should be recorded, and a justification of why they were carried out should be added. a justification as to why these have been chosen..

Next, the results obtained from the evaluation (including the diagnosis, if any) should be reflected, 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 actual problem to be treated but also also antecedents, consequences of the problem, modulating variables that may interfere or maintain a problem and how all these factors are related to each other. that may 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 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 include the different practices and actions carried out by the person issuing it, as well as the results of the intervention. Possible changes that may have had to be made should also be recorded.

It is very important to reflect the evolution of the subject or situation, as well as the psychological psychological evaluation tests and methods that may have been carried out to assess it, if applicable. to evaluate it in the case of being applied. It will be evaluated if the treatment has been effective or not and if the need to continue or modify it is considered. Also if the patient is discharged or if a referral is made.

8. It should be understandable and useful for the reader

When writing a report, it is essential to bear in mind that it is made so that other people or the same professional at different points in time can understand what has happened and what has been done throughout the process being reflected. The target audience must be taken into account: it is not the same to prepare a report full of technicalities that only another professional in the sector can understand as it is to prepare it to, for example, hand it over or give it back to the patient/client.

We must use clear and concise language that is appropriate and understandable to the target reader of the report.

9. Be objective

In a psychological report should contain contrasted datathat another person could replicate through the same procedures carried out. Thus, the report should be based on the client's observations 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.

Similarly, the inclusion of value judgments (both negative and positive) that contaminate the data or the attitude of the person reading the report (whether the person writing it, another professional or the patient/client) with respect to the case should be avoided.

10. Reflect the essentials

When writing a report, we must bear in mind that it is a text in which we are going to summarize a text in which we are going to summarize the data that we obtainIt is not a complete transcript of every interaction carried out.

We must focus on the most relevant aspects, not reflecting unnecessary information but only those 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 be finished, it is very important to take into account not only the data but also how they will be reflected or expressed. It is possible that the client or patient may not request the report in writing, but at least an oral return of the report should always be made.But there should always be at least an oral return of the report. And such a return is of great importance, since it can have a direct effect on the patient or client.

How it is explained can be as or more important than what is explained: it is not the same, for example, to tell someone point-blank that he or she has a disorder than if it is explained in an understandable way, tactfully and without generating stigmatization.. Space should also be left for the subject to express doubts, so that they can be resolved.

It should be taken into account that the report is delivered finished, whether it is because the incident, problem or disorder in question has been solved or if there is a referral to another professional who continues working with the case.