How to write a psychological report, in 11 steps

At some point in our lives it is likely that we will have to prepare or receive some type of report, be it on a personal or professional level. Whether it is to analyze the state of a specific entity, object or situation or its evolution over time, as well as to justify a specific action or the need for it or To assess the presence of changes based on this, in many cases we will have to report them to inform other people of our activity or what has happened. happened.

The field of psychology is no exception, especially in the clinic: we must write a report for each patient or client that we have in which we detail your data, problems, results of evaluations, treatments or interventions applied and results. But writing a report correctly may not be as straightforward as it sounds. In this article we are going to observe a series of steps to answer the question of how to do a psychological report.

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11 steps to writing a psychological report

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

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

Although it may seem obvious, the first step to make a report correctly is to know what we are doing it for, the type of report and the data that we are going to reflect on it. This will allow the information to be structured in one way or another and the most relevant data for the case to be clearly reflected.

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2. Informed consent

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

3. Gather and structure information

A report does not start from scratch: it is necessary first collect data on the subject or situation to be analyzed or described, paying attention to as much detail as possible.

The information that we write down will serve us later to write the report. Likewise, it is necessary to be clear about the structure that the report is going to follow, which will vary depending on the objective it has. The next four steps actually refer to the structure in question.

4. Basic facts first

To write a report we will need as we have said a large amount of data, which in order to be understandable we will have to structure in various areas. In a psychological report, the basic demographic data of the patient or client, who requests the report and / or its objective, will be taken into account first, a brief description of what is happening to you and what causes the data of the center and professional who is attending or making the report to have come to us.

5. The case evaluation process: evidence and results

After the most basic data, it is necessary to go into detail by first stating the information extracted from the initial evaluation. Each one of the tests and interventions carried out must be included, with the possibility of adding a justification for why those in question were chosen.

The results obtained from said evaluation (including the diagnosis, if any) will be reflected below, showing the specific data obtained. This information can be divided into several subsections (for example, intellectual capacity, personality, socialization, etc.), but they must allow an integrated image of the case to be formed in question. In the case of clinical practice we must take into account not only the current 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 relate to each other.

6. It reflects the objectives and the 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 that are set to be achieved with a possible intervention, negotiated with the patient or client. In another section the intervention plan that has been followed during the case will be detailed.

7. Results and follow-up of the intervention

The report must include the different practices and actions carried out by the person issuing it, as well as the results of said intervention. Possible changes that have had to be carried out should also be recorded.

It is very important to reflect the evolution of the subject or situation, as well as the psychological evaluation tests and methods that may have been carried out to assess it if applied. It will be assessed whether the treatment has been effective or not and whether the need to follow it or modify it arises. Also if you are discharged, or if there is a referral.

8. It must be understandable and useful to the reader

When writing a report, it is essential to take into account that it is carried out in order that other people or the same professional at different times can understand what happened and what happened throughout the process that is being reflecting. The target audience must be taken into account: it is not the same to make a report full of technicalities than just another professional in the sector can understand that preparing it for, for example, delivering it or making a return to the patient / client of the happened.

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 verified data should appear, that another person could replicate through the same procedures carried out. Thus, it should be based on what is reflected by the client 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 who reads the report (be it the subject who writes it, another professional or the patient / client) regarding the case.

10. Reflects the essential

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

We must focus on the most relevant aspects, not reflecting unnecessary information but only the 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 consider not only the data but how it will be reflected or expressed. It is possible that the client or patient will not get to request the report in writing, but there should always be at least one oral return of it. And this 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 drop someone point-blank who has a disorder than if it is explained in an understandable way tactfully and without stigmatizing. You should also leave room for the subject to express doubts, so that they can be resolved.

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