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...
The "results" section should integrate the data from the other sections. Finally, the "summary and recommendation" sections will include relevant information to the DSM diagnosis. Recommendations for further treatment should also be introduced.
Psychological reports are useful because of their treatment-focused approach. They provide comprehensive background information, the patient's history of previous responses to and between treatments and objective assessment data. They are evidence-based in the way they pose a psychological 'problem' that that is then 'answered' by concrete treatments recommendations. While only the beginning of the therapeutic process, they encourage a holistic model to dealing with patients that can be understood quickly by a variety of specialists.
Reference
Nail, Greg. (1997). Psychological evaluation. MS Resource.
Retrieved December 3, 2009 at http://www.msresource.com/format.html
