How to Compose a Report in Clinical Psychology

Here we'll tell you everything you need to know about a report in clinical psychology and how to compose this important piece of psychological intervention.

Every psychological evaluation process ends with the communication of its results through a report. Therefore, this report must be truthful, objective, and transparent, due to the scientific and rigorous procedure it’s been through. We’ll now bring you a guide to writing a report in clinical psychology.

This way, you can have it as a guide and know how to proceed and where to place the information obtained in the interviews, tests, and questionnaires.

Characteristics of a report in clinical psychology

• It must be a scientific document. Because of this, the information must be well-defined and nothing, or almost nothing, should be left to speculation.
• It’s a means of communication. The language used, and its content, must be adapted to the specific case being dealt with. It must be technical but, at the same time, understandable to both professionals and patients.
• Finally, it must be a useful and relevant document for the case in point. It must also add value to the evaluation.

Based on Fernandez-Ballesteros’ report proposal (2014), we propose the following model for a report in clinical psychology:

1. Initial data

Information about the evaluator and the person evaluated

The following information must be recorded about the examinee: name, gender, age, address, telephone number, profession, and academic level. In addition, the evaluator must specify their name, studies, college accreditation, and date of the evaluation.

Objectives and personal references

The reason for the consultation and/or the reasons for the current evaluation must be made explicit. Don’t forget the objectives that are going to be set for the case.

Biography

You need to add a brief summary of the patient’s life that includes the most significant facts. For example:

• Birth.
• Studies.
• Family.
• Profession.
• Current situation.

We must also stipulate the development of the situation or problem that brought the patient to the consultation.

2. Procedure and techniques used

Make a list of the techniques, tests, questionnaires, etc. used to obtain the information. In addition, it’s necessary to indicate the raw data obtained in the tests (especially if the report is going to be remitted to another psychologist).

Psychological evaluation is a scientific procedure. Thus, the data collected may also be useful to other professionals. For this reason, the professional should present it in a format that furthers its usefulness.

Finally, if the psychologist has used any specific tool to record the interview in audiovisual format, then they should state that in this section. But be careful here as, according to the Data Protection Act, such material is confidential.

3. Behavior during the exploration

Observe and record the pertinent motor and verbal behavior that has taken place during the evaluation process.

In addition, it’s necessary to record the degree of cooperation and commitment of the patient (if they’re collaborative or not, if they resist in any way, etc.).

4. Results

In this section, the psychologist will indicate the results of the evaluation, on which they’ll make their judgments and affirmations. It comprises the following sub-sections:

Behavior studied

This section specifies the most salient behavior or attitudes observed during the exploration and divides them into behavioral, cognitive, physiological, and verbal levels.

Personality and behavioral repertoires

In this section, the expert should specify everything that refers to the cognitive, behavioral, and physiological-emotional characteristics that remain constant in the patient.

Information pertaining to intelligence, memory, and abilities can also be included, if the case requires it. In addition, they can make reference to attitudes, motivations, expectations, and, also, to sensory-motor functions such as laterality, coordination, visuospatial organization, etc.

Environmental conditions

This sub-section includes everything that refers to the patient’s environment and surroundings, and that may be adversely influencing their behavior.

Biological aspects

Here, the psychologist will record the investigations of other professionals that they deem worthy of reference and that may be relevant to the patient’s current situation.

5. Treatment

Here, the professional must specify what areas of the patient’s life and behavior they intend to treat, as well as the specific treatments they’ll use.

The ideal thing here is to be able to quantify the result of the treatment through the quantification of the assessments. This way, you can make a comparison between the initial level and the final post-treatment phase.

If the initial objective of the report was simply the diagnosis, this is where the report will end. However, if the purpose is the treatment, then it’ll be necessary to continue with the process and move on to the next section.

6. Evaluation of the treatment

The expert will need to analyze and specify the changes that have occurred in the factors and areas that they wanted to treat. They’ll also need to state if the proposed objectives have been met.

In addition, they’ll need to point out the impact that the treatment had on the patient and their environment.

Finally, we’d like to recommend a follow-up evaluation after three months, six months, and then a year.