Psychological Reports: Why Good Psychological

Psychological Reports: Why Good Psychological Report Is an Integral Part of Treatment A psychological report gives an overview of the client that can provide a starting-point for the therapist when he or she is beginning the therapeutic process. It can also enable the client to be more quickly referred to specialists, if psychotropic drugs or other types of specific therapies are required. The report must be thorough, organized, balanced, and factually accurate.

The first section of a psychological report is entitled "purpose of evaluation" and gives a brief introduction to the patient's demographic data and reasons the client has sought treatment (Nail 1997). The second section is devoted to "assessment procedures" and notes the types of tests used to diagnose and evaluate the client, who administered them, and for how long (Nail 1997). These forms of assessment may be formal, such as the MMPI, as well as informal, such as an interview.

This section demonstrates the justification for the patient's diagnosis and likely efficacy of different types of treatment. It enables the therapist to review the objective results of various assessments and if necessary contact the individuals who interpreted the test results and/or interacted with the patient. If the assessments do not seem accurate, the therapist may question the client's diagnosis and recommend a more comprehensive evaluation. The third section presents the client's "background information" (Nail 1997).

Unlike a diagnostic code, this contextualizes the patient's illness in light of his or her personal history. This may include the client's family situation and mental health history, social and medical needs, and also possible legal issues surrounding the patient's case. Past treatment should be detailed, and also the patient's behavior between treatments. The reason for treatment failure or noncompliance should be cited to avoid repetition of unsuccessful treatment (such as unresponsiveness to different therapeutic types, or reactions to specific drugs). Usually, this section is in chronological order (Nail 1997).

Next, there should be a paragraph about the present reasons for referral, detailing the onset of the present complaint, and how it compares to previous problems suffered by the client. The final paragraph should summarize the observations of staff about patient behavior and level of motivation regarding the current admission or referral, as well as medications currently being used by the patient, especially if the patient was taking them at the time of the evaluative testing.

This may affect the accuracy of the report, and the severity of the patient's symptoms. Next, there is a section entitled "mental status examination," of the therapist's own observations, impressions, and assessment when meeting with the patient (Nail 1997). Physical health, appearance, and speech should be recorded, even if there are no abnormalities. Next, the "results of the evaluation" should be introduced. While there are several different models for writing reports, for most mental health status evaluations, the Hypothesis Testing Model is favored (Nail 1997).

In the MSH model, possible answers are posed to the referral questions included in the "purpose of evaluation section" and data is introduced in the results section that might confirm or refute the initial.