Scribd
Upload
107 views5 pages

Psych Report Sample 2

Uploaded by

Ling Capelo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
107 views5 pages

Psych Report Sample 2

Uploaded by

Ling Capelo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 5

STRICTLY CONFIDENTIAL

PSYCHOLOGICAL EVALUATION

Name :
Age:
Gender:
Address:
Dates of Testing:
Date of Report:

PURPOSE FOR EVALUATION: Rather than "Reason for Referral" the first
section for the report is better called "PURPOSE FOR EVALUATION." This gives
you a lot more flexibility. If you use "Reason for Referral", you pretty much must
copy whatever the consult says. Unfortunately, many consults ask questions which
tests can't answer (or else they don't ask any question at all).

Use this section to briefly introduce the patient and the problem. Begin with a concise
"demographic picture" of the patient. (e.g., The client this 28-year-old, single who has
13 years of formal education and is employed as _________. She was admitted due to
symptoms of major depression.

Use this section to tell your reader what issues you will address in the body of the
report. In this way, he won't get to the end of your report, then have to think back to
decide whether your conclusions were supported by your data. He'll know on what
issues to focus, and he can be forming his own impressions while he's reading. (e.g.,
The purpose for the current evaluation was to screen for evidence of depression and
clarify the nature of the underlying symptoms.) In sum, use this section to "pose a
question," which you will answer in the "SUMMARY" section.

Finally, if the evaluation takes more than 5 days to complete, you should put a
progress note in the patient's chart giving preliminary test results. For example, you
might conclude the "PURPOSE FOR EVALUATION" section of your report with,
"Preliminary results were reported in the patient's progress notes on _______. The
current report will supplement and elaborate upon those preliminary findings."

ASSESSMENT PROCEDURES: Refer to this section as "ASSESSMENT


PROCEDURES" rather than "TESTS ADMINISTERED." This allows you to include
the Mental Status Exam and the Clinical Interview as two of your procedures. This
also helps communicate to referral sources that you do more than give some tests and
copy interpretive statements out of a manual. It lets them know that your evaluation is
a professional integration of information from a variety of sources. Be sure to also
note who gave the tests and how long it took. These issues are important if a case
ever goes to court.

e.g.: Millon Clinical Multiaxial Inventory-III (MCMI-III)


Minnesota Multiphasic Personality Inventory-2 (MMPI-2)
Mental Status Examination
Review of Prior Psychological Assessment
Review of Prior Medical Records
Clinical Interview

6 Virtues and 24 Character Strength Test, MBTI, HEXACO-PI, SACKS Sentence


Completion Test.

This patient participated in 3 hours of testing and a 1-hour diagnostic


interview. Self- administered.

BACKGROUND INFORMATION: In this section present paragraphs dealing with


family, social, emotional aspect of the client. Only include those issues that are
relevant to the "questions" posed under "PURPOSE FOR
EVALUATION." Excessive, unnecessary details will distract the reader from the
case you are trying to build in support of your conclusions! Whenever
possible, MAINTAIN CHRONOLOGICAL ORDER when presenting background
information.

Next describe the patient's history of substance abuse/mental problems, and mental
health care in CHRONOLOGICAL order. Where possible, provide enough details of
prior intervention efforts to clarify what was attempted and whether it was
successful. Your goal is to encourage replication of prior successes and/or avoid
duplication of prior treatment failures. Also, be sure to describe the patient's behavior
and level of adaptive functioning BETWEEN prior interventions. These details will
help give the treatment team an idea of what "target level" of adaptive functioning to
shoot for in the current intervention. Follow with a paragraph describing the onset
and development of the present illness/ exacerbation. Let the reader get an idea of
how the current admission compares to prior admissions and what specific events
precipitated the current admission. End this section with a brief paragraph
summarizing staff observations, patient behavior, level of motivation, etc. during the
current admission. Keep in mind that objective observations by professional staff are
one of your best sources of data. Conclude with a sentence indicating medications
being taken at the time of testing.
MENTAL STATUS EXAMINATION: Focus on YOUR observations and
impressions. This section of the report should focus on your objective
evaluation. Avoid quoting the patient's opinion of his own mood, affect, etc. It's also
best to avoid mixing in background information or test information with this
section. A typical MSE for a 'normal' patient might read:

Example 1:

Results of mental status examination revealed an alert, attentive individual who


showed no evidence of excessive distractibility and tracked conversation well.
The patient was casually dressed and groomed. Orientation was intact for
person, time and place. Eye contact was appropriate. There was no abnormality
of gait, posture or deportment. Speech functions were appropriate for rate,
volume, prosody, and fluency, with no evidence of paraphasic errors.
Vocabulary and grammar skills were suggestive of intellectual functioning
within the average range.

Example 2:

The patient's attitude was open and cooperative. His mood was euthymic. Affect
was appropriate to verbal content and showed broad range. Memory functions
were grossly intact with respect to immediate and remote recall of events and
factual information. His thought process was intact, goal oriented, and well
organized. Thought content revealed no evidence of delusions, paranoia, or
suicidal/homicidal ideation. There was no evidence of perceptual disorder. His
level of personal insight appeared to be good, as evidenced by ability to state his
current diagnosis and by ability to identify specific stressors with precipitated
the current exacerbation. Social judgment appeared good, as evidenced by
appropriate interactions with staff and other patients on the ward and by
cooperative efforts to achieve treatment goals required for discharge.

Example 3:

Mental Status Examination upon consultation: The patient is an adult, Filipino,


male, appeared as stated age, average build, appropriately dressed, and well-
groomed. No psychomotor retardation nor agitation. Normal posture, good eye
contact, with no unusual mannerisms or gestures. He was cooperative and
attentive towards the examiner. The mood was described as depressed with
mood-congruent affect, mostly constricted but appropriate.
The speech was spontaneous, fluent in dialect, with no word-finding difficulties
and other language defects. The tone was anxious with normal volume, rate, and
amount. The thought process was coherent, and goal directed. He denied
hallucinations: no delusions, paranoid thoughts, suicidal ideations, homicidal
urges, nor obsessions.

RESULTS OF EVALUATION: There are several models in writing a


psychological report. For most evaluations the Hypothesis Testing Model is
recommended. In this model results are focused on possible answers to the referral
question(s). The idea is to present a hypothesis in the "PURPOSE FOR
EVALUATION" section, then present data systematically to support or refute the
hypothesis. Separate paragraphs in the "RESULTS OF EVALUATION" section
address theoretical/ conceptual issues by integrating data from the history, mental
status exam and behavioral observations with data from all the tests.

The strength of this model lies in its efficiency and concise focus on the referral
problem. The reader isn't distracted by unrelated details. The primary weakness of the
model is that you don't report some of the information which is unrelated to the
"PURPOSE FOR EVALUATION" but which could potentially be useful to other
disciplines.

SUMMARY/RECOMMENDATIONS: Begin by specifically answering the


questions you posed under "PURPOSE FOR EVALUATION." Then elaborate as
much as needed to present your conceptualization of the case. It's fine to include
DSM diagnostic impressions, but your summary of the patient's psychological
makeup is far more important. If you do include DSM labels, be sure you've provided
enough detail in the body of the report to support the diagnostic criteria as described
in DSM. Any recommendations for treatment can also go here. For example:

Results of psychological evaluation reveal that


________________________________________________________________
________________________________________________________________
________________________________________________________________

It is recommended that efforts to establish a trusting relationship with this


patient be continued, to help him cultivate a more adaptive coping/defensive
pattern. Individual therapy will be more productive than group interventions.
Once his guardedness has been relaxed, it will likely be beneficial to explore
psychosocial issues present at the time.

___________________________________________
Please let me know if any additional information is needed concerning the results of
this evaluation.

_________________________ ____________________
Psychology Associate Psychologist II

You might also like