PSYCHOLOGICAL REPORT WRITING TIPS
Inservice by Greg Nail
Mississippi State Hospital
December 6, 1990
(includes subsequent revisions)
- There is no one "correct" way to write a report. It needs to be unique
to the writer and the patient. Styles often change with each report written.
However, there are some basic guidelines that will help to write reports (regardless of
style issues) clearly and meaningfully.
- Purposes for the report can vary, they include:
- Answer specific questions
- Treatment planning
- Formulate/conceptualize the case
- Monitor progress
- Provide diagnostic input
- Assess therapy outcome
- Facilitate prognostications
- Tailor the report to the reader with respect to his training, his familiarity with
terms, uses for the report, and what questions he is asking. Address the referral
question. If the question is inappropriate or can not be answered with psychological
assessment, you may need to consult with the referral source and modify the
question. Don't just copy the question from the referral sheet. Use this
section of the report to state the "Purpose of the evaluation." Word the
referral question to cue the reader as to what confirming/refuting data to focus on while
reading the report. Tell him what case you are building. (e.g., let him know to cue
in on the Avoidant Personality issues.) You don't want him to get to the end of your
report, then have to read it again to see if your conclusions were supported. Let
him be forming this judgement while he reads.
The referral question can help the reader get a better understanding of what psychological
assessment can potentially provide. Address unwritten needs of referral source, such
as objective confirmation of diagnosis, presence/absence of risk factors for aggression,
- Standardized Format for Psychological
Reports- everybody has his own preferences, making it difficult to agree on a standard
format. However, the advantage of consistency in the format is that you know where
to look for specific details when reading other people's reports. Developing a
consistent format also helps you avoid omitting info and speeds up report writing.
You don't have to re-invent the wheel for each report. Just modify its design a
- Improve report writing with good structure. The goal of the report is to reach a
logical conclusion that answers the referral question(s) and is supported by valid,
reliable data. Use the body of the report to establish credibility for your
conclusions. You have 3 sources of data:
/ BEHAVIORAL OBSERVATIONS \
CLINICAL HISTORY \ MENTAL
STATUS EXAM / TEST
If any one of these is missing (e.g., test data), you still have two sources of data
for the report!
- Have a plan or general outline in mind when you start writing. Know where you're
going; what conclusions you're building toward. If you start writing with the idea
that you'll figure out some conclusions when you get to the end of the report, you'll need
to do extensive rewriting to make the report flow smoothly and to remove the unnecessary
- Within this framework you want the report to flow smoothly, so that minimal effort is
required of the reader to organize the data. Help him assimilate the information by
giving him an efficient structure. Let him concentrate on understanding the patient,
rather than being distracted by trying to "put the pieces together."
- in the Referral Question you told him what information to look for in the report
- now give him a "gestalt", a framework on which to place all the details you
are about to present. Do this with a concise demographic description at the beginning of
the Background Information section. Let him get a mental image of the patient you are
describing. (e.g., This is the first MSH admission for this 36 year old, single, white
female who has 13 years of formal education and is employed as a sales clerk.)
- Present the details in a meaningful, orderly, and functional manner.
- Group related pieces of information together in a single paragraph. For example,
put all information concerning family, friends, marriages, interpersonal conflicts, etc.,
in a single paragraph dealing with social issues. Use separate paragraphs only if
you want to emphasize a particular issue, such as the precipitating influence of marital
conflict on the current illness...or retardation in the development of coping skills due
to abuse during childhood.
- Use good paragraph structure. The first sentence of the paragraph tells what the
whole paragraph is about. The last sentence sums up the paragraph.
- Within each topic, follow a chronological development. You don't want the reader
to have to stop and figure out which admission came first or which symptoms appeared last,
- Keep information under the appropriate subheading. Don't put Mental Status details
or behavioral observations under Background Information, or vice versa.
- Be consistent in your form. If you give the details of the first marriage (or
hospitalization, or reasons for medication changes), give the details of all marriages,
etc. Where this isn't possible, let the reader know which information is not
available, or why you elaborated on one event and not the other.
- Report information clearly and with confidence. Avoid excessive use of words like
"reportedly; according to the patient; or the patient stated." Once you've
made it clear that the history came from clinical interview, you don't need to repeatedly
qualify the data. Excessive use of these words tell the reader that you lack
confidence in your data and/or your ability to judge the reliability of the
informant! One way to avoid this is to use quotation marks occasionally to let the
reader know you are relating the patient's opinions.
- Qualifiers are important at times, but excessive use reveals indecision or
uncertainty. Avoid excess use of "appears to, suggests, may be, apparently,
etc". Rather, say "The patient is..." Use of behavioral
descriptors can help here. For example...
|The patient may have conflicts
dealing with authority figures.
|The patient's difficulty with authority figures
is evident in his multiple expulsions from
school, arrests, and frequent loss of jobs due
to "personality conflicts" with employers.
- Include only details that are relevant to your conclusions. Excess details
distract the reader from the case you are building in support of your conclusions.
For chronic schizophrenia you might spend several paragraphs on past treatment efforts and
only a sentence or two on family issues. For an avoidant personality disorder, you
might spend several paragraphs on family and other interpersonal issues, while devoting
only a couple of sentences to prior treatment. Remember, the purpose of the
psychological report is usually NOT to provide a comprehensive social or medical
history. Include only relevant details.
- Generally, don't repeat information. If paragraph one stated that the patient has
been repeatedly fired from jobs, don't repeat this in paragraph four as part of the
"social issues" paragraph. Find a way to convey all the information and
only say it once. Exceptions to this rule include repetition for emphasis and
limited repetition in the summary.
- Diagnose, conceptualize, or both? Opinions differ as to whether the report should
emphasize formal DSM diagnosis or focus on an effort to conceptualize the case (i.e.,
present a systematic description of the individual, his problem, how the problem
developed, and the forces which maintain the problem). In my humble opinion...
- DSM categories do a poor job of helping therapists understand individuals
- Psychological tests are poor predictors of DSM labels. (However, the combination
of test data and clinical inference does improve the reliability of DSM diagnoses)
- Psychological evaluation is used most effectively when the emphasis is on
conceptualizing the case, rather than generating a DSM diagnosis.
- It is appropriate to include a DSM diagnosis, so long as you also provide a
"paragraph style" conceptualization of the case. Don't just label the person. Go
beyond DSM and help your reader understand the individual.
- The uniqueness of psychology centers around our theories and efforts to make sense out
of the distorted clinical picture. For example...
|Results of this evaluation
reveal the presence of
an avoidant personality
|Results of this evaluation reveal the presence
of an Avoidant Personality Disorder, as
evidenced by (list the relevant DSM criteria).
This patient displays a chronic inability to
establish and maintain satisfactory interpersonal
relationships (or to maintain employment). He is
relatively anxious individual who experiences
marked internal conflicts over dependency
issues. He has intense, unmet needs for
attention and affection. However, his
emotionally abusive childhood has led to
extreme fear of rejection or humiliation in
interpersonal relationships. His cool, detached
public presentation represents a defensive effort
to shield himself from emotional pain.
- The TEST RESULTS section is more appropriately titled RESULTS OF ASSESSMENT.
In this section you want to do more than just copy the interpretive hypotheses out of the
manual or from the computer printout. Describe the individual, not the tests. In general
there is no need to mention specific tests by name (IQ tests are an exception). Rather,
present those portions of the test data which you can confirm during the diagnostic
interview, from collateral reports, or from review of records.
Statements such as "Individuals who obtain similar profiles.." or "These
patients tend to..." suggest that you are unsure whether or not the data fit this
specific patient. The report is more individualized when it reads like.... "Mr.
Jones prefers to (describe the relevant trait) as is evident in (some specific thing he
has said or done)".
- Where inconsistencies exist between tests (e.g., MMPI-2 vs MCMI-III) try to figure out
WHY there is a discrepancy.
- If the patient is too psychotic, disorganized, or uncooperative to be evaluated, then be
specific about why you were unable to complete the evaluation and what efforts you took to
try to motivate cooperation. Be sure your reader understands that you put forth
appropriate effort. Even in cases like this, you can still write a report.
Your description of the type of uncooperativeness encountered is important (e.g., Repeated
efforts to conduct psychological evaluation were unsuccessful. The patient refused
to answer most questions and became hostile when encouraged to participate. Efforts
to establish rapport were impaired by extreme paranoid ideation exhibited during the
- Stating that a patient is psychotic tells little about the problem. Be specific...
(e.g., Results of psychological evaluation reveal the presence of a psychotic thought
disorder characterized by disturbed thought process with relative integrity of thought
content, and no clear indication of ongoing perceptual disturbance.
- Distinguish between disturbance of thought content vs. disturbance of thought process.
- When hallucinations are present, be specific about the type (auditory, visual, tactile)
and about their content.
- Be specific about the content of delusions and note whether they are systematized.
- If there is a disturbance of thought process (i.e., formal thought disorder) be specific
about what is abnormal. Thought process can be described as "intact and goal
oriented; well organized; significant for marked loosening of associations; tangential;
- Address both the "range" and "appropriateness" components of
affect. Range refers to fluctuations in affective presentation and can be described
as normal, restricted, blunted, etc. Appropriateness refers to the consistency
between what the patient says versus his facial expression and tone of voice.
- State which "negative symptoms" of psychosis are present. These include
impoverishment of emotional expression, reactivity, or feeling; impoverished thinking or
cognition; disturbance of thought process; poor grooming; impersistence at work; physical
inertia; general lack of energy,drive or interest; decreased pleasure in recreation, sex,
- Avoid using jargon or terms for which there is little consensus as to their
meaning. State what you observe rather than just saying ....impaired "reality
testing", or that the patient appeared "characterological",
"neurotic", or that he displayed "cognitive slippage", or
- Avoid vague comments that don't really describe the patient or changes in his
status. For example...Rather than saying the patient "improved" on Haldol,
state what changes were observed that suggested improvement. Were there specific
changes in mental status, self care,...etc.?
- Be sure to use the terms reliability and validity correctly. Misusing these terms
is the psychological equivalent to saying "ain't" in English class and is second
only to, "The data is.." when it comes to destroying your credibility in the
eyes of other psychologists.
- There is no such thing as an "invalid" MMPI. You can always gather
inferences from the data, even if it's only an explanation of why the F scale was so high
and all the clinical scales are so elevated. In general, you can avoid confusion by
not specifically mentioning the "validity" of the MMPI. However, if the
validity issue is addressed in the report, an appropriate option might be to say something
like... "Results obtained on the MMPI-2 were psychometrically invalid. However,
the resulting clinical profile was partially consistent with the client's history and
clinical presentation in that...." An even more attractive option would be to
avoid using the term validity, and just address the specific reliability/validity points
that tend to be (inappropriately) lumped together under this heading. For example:
"The client responded to objective testing with excessive endorsement of pathological
items, suggesting a deliberate effort to present himself in a negative manner. He
scored particularly low on scales addressing psychological defensiveness and tended to
endorse obvious indicators of psychopathology much more frequently than relatively subtle
indicators of similar problems. Furthermore, he failed to provide consistent answers
to similarly worded test times, possibly suggesting inattentiveness to the task.)
- When referring to yourself in a report there is no clear consensus whether you should
use personal pronouns or refer to yourself as "the examiner." Many
psychologists feel that referring to yourself in the third person makes the report sound
more objective and formal. Others (including myself) feel that it makes the report
sound awkward and stilted. One option is to find ways to avoid references to
yourself. For example,
|The patient was angry with
me for interrupting his
scheduled activities on
|The patient voiced frustration and
hostility over disruption of
scheduled ward activities.
- It is sometimes appropriate to do a relatively cursory assessment in order to give rapid
feedback to the referral source. This is often the case on receiving units where the
patient may provide an unreliable history and access to medical records or family members
is delayed. In these cases I recommend including "qualifiers" in the
report in order to let the reader know that additional useful information is potentially
available from psychological assessment. They also cue the reader that the data have
not necessarily been verified. For example,...
Under Purpose of Evaluation...rather than saying the patient was referred for
psychological evaluation, you could say that he was referred for "psychometric
In the Summary.....rather than saying "Results of psychological evaluation
indicate..." you might say "Results of psychometric screening
The last sentence of the summary could read.. "These results of psychometric
screening should be viewed as tentative, until confirmed by further clinical
- Rather than having a section called "Tests Administered", I recommend calling
it "Assessment Procedures." Under this section you can then list
"Clinical Interview" and "Mental Status Examination" along with the
tests. This helps communicate to the reader that your evaluation is an integrated
evaluation, not just a list of test results. In this section you might also list
"Review of Prior Psychological Assessment Dated ------", "Interview
With Joe Blow (patient's brother)", "Review of Medical Records."
- Try to vary your sentence structure, throwing in some dependent clauses. This will
make the report more readable. However, it's best not to get so "flowery"
that its hard to understand. You don't want the reader to have to reread a sentence
to figure out what you are talking about.
|Never having attained gain-
ful employment, the patient,
a precocious, intellectually
gifted, young man who
dropped out of school after
fifth grade owing to personality
conflicts with his geography
teacher, a demanding, overly
critical authority figure, is
excessively resentful of
|Despite his superior intellectual
ability, the patient's excessive
resentment for authority figures
and external demands has led to
chronic impairment of academic
and vocational success.