Report Writing

1
Report Writing
2
Semester

• Report 1 due tomorrow
• No report 3
• Test presentation

3
Report Writing

• No consensus on writing report
• When you get to practicum site, ask for sample
  report
• Style is usually context specific
• Learn style, then work within these parameters
• Content of report should not exceed training or
  expertise

4
Basics

• Avoid jargon
• Contractions
• Informal speech
• Be specific, use behavioral examples
• Simplify language (no big words)

5
Basics

• 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, 
•  (WEAK) The patient was angry with  me for
  interrupting his  scheduled activities on  the
  ward. 
• (Better)The patient voiced frustration and 
  hostility over disruption of  scheduled ward
  activities.

6
Purpose

• Answer specific questions
• Treatment planning 
• Formulate/conceptualize the case
• Monitor progress 
• Provide diagnostic input
• Assess therapy outcome
• Facilitate prognostications
• Sattler
• Communicate to referral source
• Serve as source of hypothesesfor evaluation
• Baseline information
• Legal document

7
Preparing to write

• Think of report as you conduct your assessments
• Try to write reports, at least Observations,
  immediately after testing
• Report writing is tedious
• Dont procrastinate
• Set deadlines

8
Typical Sections

• Identifying information
• Assessment Instruments (techniques, procedures)
• Reason for referral
• Background information
• Observations during the assessment
• Assessment results and clinical impressions
• Summary
• Signature
• Table of scores
• Other
• Signed release, intervention, follow-up

9
Section Demographics

• I prefer two columns at top to condense space
• Include all relevant information
• Name
• DOB (always clarify, dont just take childs
  word)
• DOE
• Education
• Gender
• Examiners name
• Name of school/organization
• Optional handedness, school address, phone
  number

10
Reason for Referral

• Potential uses for the evaluation
• Clarify, Clarify, Clarify
• Include
• name, position, etc. of referral source
• Why
• Specific questions
• Behaviors that led to referral source
•  Answer the referral question(s).
• Provide the referral source with information
  about the client which can be used in his
  treatment.
• To provide treatment recommendations and/or
  facilitate diagnosis.
• Establish an objective record of the patient's
  current functional and adaptive status, which can
  serve as a baseline for comparison after
  treatment has been implemented. 

11
Background Info

• Tell a story
• Current problem
• Maturational/developmental history
• Medical history
• Educational history
• Social history
• Family/caregiver history
• Interview material (according to X reported
• Previous testing

12
Observation during assessment

• Keep relevant
• Be specific, support inferences
• Physical appearance, demeanor , mood
• Capture important behaviors not readily testable
  (e.g. impulsivity, shyness)
• Validity of effort

13
Assessment Results

• List of tests (Assessment procedures, techniques,
  etc.)
• Provide in a logically ordered format
• Test Focused vs. Function Focused
• Discrepancies
• No standard
• Make meaningful
• Scores
• I prefer (SS?, PR?) for broad scores
• Some prefer no numbers

14
Interpretive Depth

• 1. Textbook copying
• 2. Some interpretation of individual
• 3. Highly interpreted, specific to individual,
  integrates multiple sources of information

15
Summary

• Summary before recommendations
• Integrate information
• No new material
• Your final Answer for special ed.
• Many only read Summary

16
Strong Summary

• 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...
•   (BETTER)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.

17
DSM diagnosis

• 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.

18
Recommendations

• No Barnum Effects
• Link to classroom
• Explain
• Make reasonable concerning resources
• Goals
• Reevaluations and follow-up

19
Feedback

• Some SP present, some not
• Use graphs and visuals
• Meet with attendees early