psychology patient report

by Damon Jast 9 min read

9+ SAMPLE Psychological Assessment Reports in PDF

8 hours ago How to Write a Psychological Assessment Report Step 1: Make the patient relax.. Before having a psychological assessment, you must first examine the person. As you... Step 2: Do the test with care.. As you do the interview with the patient, you must … >> Go To The Portal


How to Write a Psychological Assessment Report

  • Step 1: Make the patient relax.. Before having a psychological assessment, you must first examine the person. As you...
  • Step 2: Do the test with care.. As you do the interview with the patient, you must do it with proper care. Speak in a...
  • Step 3: Analyze the data.. As you finally have done your best in interviewing the...

Full Answer

What is the psychological report sample?

The psychological report sample points out them for one to understand the most significant elements of such type of work. In addition, the psychological report sample provides an example of the structure, style, and a clear outline of the psychological report. Date of birth: 11.08.05 Source of referral: Ms. Adriana Blake, the mother

What are the characteristics of a report in clinical psychology?

Characteristics of a report in clinical psychology It must be a scientific document. Because of this, the information must be well-defined and nothing, or almost nothing, should be left to speculation. It’s a means of communication.

What should be included in references in a psychological report?

References should contain details of all the research covered in a psychological report. It is not sufficient to simply list the books used. Look through your report and include a reference every researcher mentioned.

What is included in the sub section of a psychological report?

This sub-section includes everything that refers to the patient’s environment and surroundings, and that may be adversely influencing their behavior. Here, the psychologist will record the investigations of other professionals that they deem worthy of reference and that may be relevant to the patient’s current situation.

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How do you write a psychology report?

Psychological Report WritingInclude a one sentence summary, giving the topic to be studied. ... Describe the participants, number used and how they were selected.Describe the method and design used and any questionnaires etc.More items...•

How do you write a psychological assessment report?

Psychologist/Examiner:Psychological Assessment Report Guidelines.Informed Consent.Reason for Referral.Relevant Background Information.Current Mental Status/Behavioural Observations.Assessment Methods.Assessment Validity. Presenting Problem.Psychological Symptoms.More items...

What is a psychology case report?

Case reports document the provisional psychologist's ability to comprehensively assess clients and provide appropriate interventions within recognised psychological frameworks.

What are the key elements to a psychological report?

The psychological report generally contains the following elements:The date of the assessment, and the client's name, sex and date of birth.The origin and description of the question (the assignment).Progress of the research.Psychodiagnostic instruments used (sources of information – see below).More items...

What is an example of a psychological assessment?

The most commonly used personality tests are the Rorschach, TAT, and MMPI. The assumptions underlying projective tests such as the Rorschach and TAT are that the standard set of stimuli are used as a screen to project material that cannot be obtained through a more structured approach.

How do you write a psychology summary?

Summarize the key points of the study. In the rationale section, summarize the purpose for the study, why the researchers thought it was important and how they felt it would add to the existing literature on the subject. If the study included hypotheses, list the precise hypotheses that were stated in the paper.

How do you take history of a psychiatric patient?

Obtain the patient's recent history of presenting illness and conduct the psychiatric interview. Obtain the patient's past personal history (i.e., past medical/psychiatric history, family history Family History Adult Health Maintenance , social history Social History Adult Health Maintenance ).

How do you write a patient case summary?

How do you write a patient case report?Describe the case in a narrative form.Provide patient demographics (age, sex, height, weight, race, occupation).Avoid patient identifiers (date of birth, initials).Describe the patient's complaint.List the patient's present illness.List the patient's medical history.

How do you write a patient case study?

Throughout the whole writing process, you should support your case with evidence by citing information properly.Title.Abstract.Introduction.Client Characteristics.Examination Findings.Clinical Hypothesis/Impression.Intervention.Outcome.More items...

Why Should We Have To Undergo a Psychological Assessment?

There are various reasons why we have to undergo a psychological assessment. Sometimes we have difficulties and we have to take the psychological t...

How Can I Find a Psychologist That Can Give Me a Psychological Assessment?

In searching a psychologist, know the expertise of the particular test that you need. Then there are many ways on how you can find the psychologist...

How Much Does a Psychological Assessment Cost?

There are government services that can provide psychological assessment to you free of charge. Examples of these are schools and health centers. Bu...

How Can I Make My Psychological Report Writing Better?

Verify the solid data that you have. Be sure that you are going to include accurate information only. To have some great skills, use any psychologi...

What is psychological evaluation?

Make a list of the techniques, tests, questionnaires, etc. used to obtain the information. In addition, it’s necessary to indicate the raw data obtained in the tests (especially if the report is going to be remitted to another psychologist). Psychological evaluation is a scientific procedure.

What information must be recorded about the examinee?

The following information must be recorded about the examinee: name, gender, age, address, telephone number, profession, and academic level. In addition, the evaluator must specify their name, studies, college accreditation, and date of the evaluation.

What is psychological report?

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.

What is contrasted data in psychology?

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.

When should a psychological report be reflected?

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.

How to make a report correctly?

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 ...

Why is it important to take into account the fact that it is done?

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.

Why is it important to record changes?

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.

Is it the same to make a report full of technicalities that only another professional in the sector can understand?

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.

What is the psychology case report?

The psychology case report is an opportunity for students to demonstrate that they have developed a comprehensive formulation and a management plan for a patient that they have personally interviewed. This assessment task aligns closely with the day-to-day work produced in the psychology profession.

Report structure

The information provided in this resource will assist you with structuring information, communicating reasoning, and checking your application of English grammar in the Psychological case report.

3.Physical and Behavioral Observation

The interviews were conducted twice a week since the 12 of December until the 10th of January; there was one personal meeting with the patient and one with his mother being present weekly. James behaved acceptably, he was never late to the interview, even to those that he attended just by himself.

4.Family Background

James’ parents are divorced for four years; they stay in a friendly relationship. The boy lives with his mother but has weekly meetings with the father, he spends at least one week of the summer vacations with him. Mr. Robert Blake, James’ father, is going to get married for the second time; his fiancée, Ms. Mary Brown, is fourth months pregnant.

5.Summary

James is most likely to be concerned about his relationship with the father after his new marriage, especially considering the fact that Mr. Robert is going to have a second child. The boy is afraid of being unwanted in the new family and ‘replaced’ by the newborn baby.

7.Recommendations

The parents of the boy have to explain the situation and the future development of it to James, he needs to be ensured of being needed and loved by his father in order to feel safe and to overcome the diagnosed issues. In addition, it would be helpful for the boy to spend some time, a week or two, with Mr.

About Jane Copland

Jane Copland is a passionate PR manager at ThePensters.com – the community of freelance academic writers. She’s into writing, technology and psychology.

When were general practice records obtained?

The claimant’s general practice records from 1978 have been obtained and studied in respect of references to psychological or psychiatric symptoms/conditions which predate the matter under litigation, or occur subsequent to it, and which may be relevant to the current investigation. (a) PRIOR TO THE INCIDENT.

How many sessions of EMDR are needed?

EMDR may be useful in this respect and some six sessions may be required Whilst this form of therapy may be available within the NHS, it is a very specialised treatment and, consequently, is likely to need to be sought privately. In such circumstances therapy should be budgeted at approximately £150 per session.

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Initial Data

  • Information about the evaluator and the person evaluated
    The following information must be recorded about the examinee: name, gender, age, address, telephone number, profession, and academic level. In addition, the evaluator must specify their name, studies, college accreditation, and date of the evaluation.
  • Objectives and personal references
    The reason for the consultation and/or the reasons for the current evaluationmust be made explicit. Don’t forget the objectives that are going to be set for the case.
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Procedure and Techniques Used

  • Make a list of the techniques, tests, questionnaires, etc. used to obtain the information.In addition, it’s necessary to indicate the raw data obtained in the tests (especially if the report is going to be remitted to another psychologist). Psychological evaluation is a scientific procedure. Thus, the data collected may also be useful to other professionals. For this reason, the professional shoul…
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Behavior During The Exploration

  • Observe and record the pertinent motor and verbal behaviorthat has taken place during the evaluation process. In addition, it’s necessary to record the degree of cooperation and commitment of the patient(if they’re collaborative or not, if they resist in any way, etc.).
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Results

  • In this section, the psychologist will indicate the results of the evaluation, on which they’ll make their judgments and affirmations. It comprises the following sub-sections:
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Treatment

  • Here, the professional must specify what areas of the patient’s life and behavior they intend to treat, as well as the specific treatmentsthey’ll use. The ideal thing here is to be able to quantify the result of the treatment through the quantification of the assessments. This way, you can make a comparison between the initial level and the final post-treatment phase. If the initial objective of …
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Evaluation of The Treatment

  • The expert will need to analyze and specify the changes that have occurred in the factors and areas that they wanted to treat.They’ll also need to state if the proposed objectives have been met. In addition, they’ll need to point out the impact that the treatment had on the patient and their environment. Finally, we’d like to recommend a follow-up evaluation after three months, six mont…
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Informed Consent

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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 herwith a determined purpose, being necessary his signature and / or agreement for it. This …
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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. T…
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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 happ...
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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), sh…
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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.
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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 outto assess it …
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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 pro…
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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 wa…
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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.
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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 clie…
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Identifying Information

  • Name: James Blake Age: 11 years 5 months Date of birth: 11.08.05 Sex: Male Educational level:Fifth grade (complete) Source of referral:Ms. Adriana Blake, the mother Examiner:Judy Hallway, school psychologist Reason for referral/referral question:James’ mother is concerned about James’ problem behavior at home and at school as reported to her by his...
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Tests Administered

  • Draw-A-Person Test (date of conducting 15.12.16) Vineland Social Maturity Scale (date of conducting 28.12.16) Vineland Adaptive Behavior Scale (date of conducting 05.01.17)
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Physical and Behavioral Observation

  • The interviews were conducted twice a week since the 12 of December until the 10th of January; there was one personal meeting with the patient and one with his mother being present weekly. James behaved acceptably, he was never late to the interview, even to those that he attended just by himself. Still, he was unwilling to talk openly, especially at the beginning of the work; he was …
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Family Background

  • James’ parents are divorced for four years; they stay in a friendly relationship. The boy lives with his mother but has weekly meetings with the father, he spends at least one week of the summer vacations with him. Mr. Robert Blake, James’ father, is going to get married for the second time; his fiancée, Ms. Mary Brown, is fourth months pregnant.
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Summary

  • James is most likely to be concerned about his relationship with the father after his new marriage, especially considering the fact that Mr. Robert is going to have a second child. The boy is afraid of being unwanted in the new family and ‘replaced’ by the newborn baby.
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Recommendations

  • The parents of the boy have to explain the situation and the future development of it to James, he needs to be ensured of being needed and loved by his father in order to feel safe and to overcome the diagnosed issues. In addition, it would be helpful for the boy to spend some time, a week or two, with Mr. Robert and his fiancée as this will demonstrate him that he is a part of his father’s …
See more on blog.thepensters.com