At some point in our lives, it is likely that we will need to prepare or receive some kind of report, whether it be on a personal or professional level. Whether it is to analyze the state of an entity, an object or a specific situation or its evolution over time or to justify a particular action or the need for it or to assess the presence of changes, in many case, we will have to report it. to let others know about our activity or what has happened.
The field of psychology is no exception, especially in the clinic: we must write a report of each patient or client that we have in which we detail their data, problems, results of evaluations, treatments or interventions applied and results. But writing a report properly may not be as easy as it sounds. In this article, we will look at a number of steps to answer the question of how to make a psychological report.
11 steps to writing a psychological report
Writing a report in a clinical setting may seem easy, but keep in mind that it should reflect the whole item, person or situation to be analyzed in an understandable way. Here are some steps you can take to begin the mediation preparation process. Focus on the psychological and above all clinical relationship.
1. Be clear about what type of report you are doing, why and on what / for whom you are doing it
While it may seem obvious, the first step to writing a report properly is knowing why we are doing it, what type of report and what data we are going to think about it. This will allow the information to be structured in one way or another and that the data most relevant to the case will be clearly reflected.
2. Informed consent
An important preliminary step in writing a report, at least when it is done with respect to a person, is the consent of that person. It should appear in the report that the person knows that data is collected from them with a specific purpose, being necessary its company / signature and / agreement for it. This consent is usually reflected in the last part of the psychological report.
3. Gather and structure information
A report does not start from scratch: it is necessary in the first place request that the data of the subject or situation be analyzed or described, Pay attention to as much detail as possible.
The information we write down will be used later in writing the report. It is also important to be clear about the structure the report will follow, which will vary depending on its purpose. The next four steps actually concerned the structure in question.
4. First the basic data
To write a report we will need, as we said, a lot of data, so that it is understandable, we will have structures in various areas. A psychological report will first take into account the basic demographic data of the patient or client, who requests the report and / or its purpose, a brief description of what is happening to him and that brings you to us, the contact details of the center and the professional who assists or directs the report.
5. The case assessment process: tests and results
After the most basic data, it is necessary to go into detail by first indicating the information extracted from the initial assessment. Each of the tests and procedures performed must be included, and can be added a rationale for why they were chosen in question.
The results of the assessment will be reflected below (including the diagnosis if applicable), showing the specific data obtained. This information can be divided into several subsections (eg intellectual capacity, personality, socialization, etc.), but it should allow an integrated picture of the case in question to be formed. In the case of clinical practice, we must take into account not only the current problem to be treated but also context, consequences of the problem, modulation variables that they can interfere with or maintain a problem and how all of these factors relate to each other.
6. Reflects the objectives and the proposed intervention
After evaluating the case, it should indicate whether any type of action or intervention has been implemented. If it is a psychological report, it is necessary to reflect the objectives to be achieved with a possible intervention, negotiated with the patient or the client. In another section the intervention plan followed during the case will be detailed.
7. Results and monitoring of the intervention
The report must indicate the various practices and actions carried out by the issuer, as well as the results of the intervention. Any changes that have to be made should also be recorded.
It is very important to also reflect the evolution of the subject or the situation the tests and methods of psychological evaluation that may have been carried out to evaluate it in the event of an application. It will be assessed whether the treatment has been effective or not and whether the need to continue or modify it is considered. Also if you register, or if a referral occurs.
8. It should be understandable and useful for the reader.
When writing a report, it is essential to keep in mind that this is done so that other people or the same professional at different times can understand what happened and done throughout the course of the report. process that is reflected. It is necessary to take into account the public to which it is addressed: it is not the same thing to make a report full of technicalities that only another professional of the sector can understand than to prepare it to, for example, deliver or make a report. feedback to the patient / client of what 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 contrasting data should appear, That another person could reproduce through the same procedures as those performed. Thus, it is necessary to start from what is reflected by the client and the tests carried out and not to transcribe opinions or personal inferences. The results of the report should be reproducible by other professionals using the same methods.
Likewise, the inclusion of value judgments (both negative and positive) that contaminate the data or the attitude of the person reading the report (whether it is the same subject writing it, another professional ) should be avoided. or the patient / client) relative to the case.
10. It reflects the essential
When writing a report, we must keep in mind that it is a text in which we will summarize the data we obtain: This is not a complete transcript of each interaction performed.
We must focus on the most relevant aspects, without reflecting unnecessary information but only on the elements necessary to assess the case and its progress.
11. Prepare the return of the report
While the report writing may be finished, it is very important to consider not only the data, but also how it will be reflected or expressed. Client or patient may not be able to request the report in writing, But you should still at least give oral feedback. And this feedback is of great importance, because it can produce a direct effect on the patient or the client.
The way it is explained may be as much or more important than what has been explained: it is not the same for example to let go of someone with a cannonball who suffers from a disorder which if it is. explained in an understandable way, tactfully and without generating stigma. There should also be room for the subject to express doubts, so that they can be resolved.
It should be noted that the report is submitted complete, whether it is because the incident, problem or disorder in question has been resolved or if there is a referral to another professional who continues to work with the case.