Understanding a Psychological Clinical Report: What You'll Find it in and Why

As with any assessment process, the results of the assessment must at some point be translated and communicated. In the case of clinical psychology, this communication comes in the form of a clinical report. However, like most other forms of communication, the clinical report has no specific language format. In fact, the language of the clinical report often changes based on who it is geared toward.

If the report is meant for the eyes of a psychiatrist, then the report will be written using formal or technical language. In contrast, a report meant for a parent or school teacher of a child will more than likely be written using simple terms that can easily be understood by those unfamiliar with psychology and psychological assessment.

Despite the differences in language, a clinical report should, and is expected to, address a specific set of criteria. The first of these is the referral question. A clinical report should answer the question(s) "that prompted the assessment" (Trull, 2005).

This answer should, of course, be given after the patient's identifying information (name, sex, age, ethnicity, date of eval., and referring clinician) has been stated. The answer should be clearly stated along with an explanation. If the clinician feels that the referral question cannot be answered, then a reason for this must be given and explained.

The next section of the report should address the procedure used during the assessment. Such a specification can and may serve as clarification should questions arise dealing with validity. It is also important should the receiving party require an explanation of how the clinician obtained information and came to the conclusion reached in the previous section of the assessment.

Similarly, the receiving party may have to interpret the assessment process to a third party. An explanation of the process in the report can clarify any questions that may arise as to the nature of the assessment and make it easier on readers who are unfamiliar with psychological assessment.

Section four deals with the background of the referral question, assessment, and anything else relevant to gaining a full understanding of the client's situation. Additionally, this section provides background on the validity and reliability of the assessment itself. This can help in understanding the results and what they mean, as well as offer back-up for the answer to the referral question, and for the following section dealing with the findings of the assessment.

The impressions and findings of the clinician are an important part of the clinical report. It is here that the clinician discusses the details of the client. This is generally done in three sections (labeled "A," "B," and "C").

A) Cognitive level: current intellectual and cognitive functioning, degree of impairment, and probable cause of impairment.

B) Affective and mood levels: Mood present, degree of disturbance (mild, moderate, severe), chronic vs. acute nature of disturbance, and lability (the level to which an individual can control cognitive resources). *

C) Interpersonal-intrapersonal level: primary interpersonal and intrapersonal conflicts and significance, coping strategies, and formulation of personality.

Once these three sections have been completed, the clinician can make their official diagnostic impression of the assessed individual. This diagnostic impression deals with the most "probable" diagnosis of the individual (Trull, 2005), and the impression of the individual's cognitive functioning. This section is important for the following section as it will be used in order to determine treatment.

Lastly, recommendations are made as to the need for medication, risk assessment, and possible need for hospitalization or supervision. Additionally, treatment methods are discussed in terms of duration, mode of treatment, and frequency that treatment will need to be administered.

As previously mentioned, it is important to remember that the language of a clinical report may differ from report to report. However, it is also important that each of the aforementioned criteria are addressed. These are important in properly explaining and understanding the referral question and the client's condition.

*Trull. T (2005). Clinical Psychology, 7^th Edition. Belmont, CA. Thomson Wadsworth.