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How to write a psychological report correctly, in 11 steps

How to write a psychological report correctly, in 11 steps

March 25, 2024

At some point throughout our lives we are likely to have to prepare or receive some kind of report, be it on a personal or work level. Whether it is to analyze the state of an entity, object or specific situation or its evolution over time as if it is to justify a particular action or the need for it or to assess the presence of changes from it, in many cases we will have to give an account of them to inform other people of our activity or what has happened.

The field of psychology is not an 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 correctly may not be as easy as it seems. In this article we are going to observe a series of steps to answer the question of how to make a psychological report .


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11 steps to write a psychological report

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

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

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


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2. Informed consent

An important preliminary step for writing a report, at least when it is done with respect to a person, is the consent of the person. It must appear reflected in the report that the person is aware that they are collecting data from her with a determined purpose, being necessary his signature and / or agreement for it. This consent is usually reflected in the final part of the psychological report.

3. Gather and structure the information

A report does not start from scratch: it is necessary in the first place collect the data of the subject or situation to analyze or describe , paying attention to as many details as possible.

The information that we will write down will help us later to write the report. Also, we must be clear about the structure that the report will follow, which will vary according to the objective it has. The following four steps are referred, in fact, to the structure in question.


4. First the basic data

To write a report we will need, as we have said, a large amount of data, so that in a way that is comprehensible we will have structures in different areas. In a psychological report, the basic demographic data of the patient or client will be taken into account first, who requests the report and / or its objective, a brief description of what happens to him and that it has come to us, the data of the center and professional who is attending or making the report.

5. The case evaluation process: tests and results

After the most basic data, it is necessary to go into detail by first showing the information extracted from the initial evaluation. Each of the tests and interventions carried out must be included, and may be added a justification of why those in question have been chosen .

Next, the results obtained from this evaluation will be reflected (including the diagnosis if there is one), showing the concrete data obtained. This information can be divided into several sub-sections (for example, intellectual capacity, personality, socialization, etc.), but they must allow to form an integrated image of the case 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 can interfere or maintain a problem and how all these factors are related to each other.

6. Reflects the objectives and the intervention proposal

After the evaluation of the case, it must be reflected if any type of action or intervention has been carried out. If we are facing a psychological report, it is necessary to reflect the objectives that are proposed to reach with a possible intervention, negotiated with the patient or client. In another section The intervention plan that was followed during the case will be detailed .

7Results and monitoring of the intervention

The report must include the different practices and actions carried out by the person who issues it, as well as the results of said intervention. You should also record possible changes that have had to be carried out.

It is very important to reflect the evolution of the subject or situation, as well as the tests and psychological assessment methods that may have been carried out to assess it in the case of applying. It will be evaluated if the treatment has been effective or not and if there is a need to follow it or modify it. Also if you leave, or if a referral occurs.

8. It must be understandable and useful for the reader

At the time of writing a report, it is essential to take into account that it is done so that other people or the same professional at different times can understand what happened and carried out throughout the process that is being reflected. The public to whom it is addressed should be taken into account: it is not the same to make a report full of technicalities that only another professional in the sector can understand that prepare it, for example, deliver it or make a return to the patient / client of what happened.

We must use a clear and concise language, which is appropriate and understandable to the objective reader of the report.

9. Be objective

In a psychological report must appear contrasted data , that another person could replicate through the same procedures carried out. Thus, it should be based on what was 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 to use the same methods.

In the same way, the inclusion of value judgments (both negative and positive) that contaminate the data or the attitude of the person reading the report (whether the subject who writes it, another professional or the patient / client) should be avoided with respect to the case .

10. Reflects the essential

When writing a report we must bear in mind that it is about a text in which we will summarize the data that we obtain : it is not a complete transcription of each 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. Prepares the return of the report

Although the writing of the report may have ended, it is very important to take into account not only the data but how they will be reflected or expressed. It is possible that the client or patient does not get to request the report in writing , but you should always make 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.

The how it is explained can be as or more important than the explained thing: it is not the same for example to release to someone at point-blank that suffers a disorder that if it is explained of understandable form, tactfully and without generating stigmatization . You should also leave space for the subject to express doubts, so that they can be resolved.

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


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