Psychological report: how to write it well and model to use

Of all the documents you produce in your practice, the psychological report is probably the one that generates the most anxiety. And it makes sense: it is one of the few clinical writings that come out of clinical practice. It is going to be read by a judge, a school, a doctor or a health insurance, and every word you put is supported by your signature and your tuition.

A poorly drafted report can harm the patient, engage you professionally, or be rejected by the person who asked for it. A well done report the right thing, protect the privacy of the consultant and leave your work well standing before third parties.

In this guide we explain how to write a correct psychological report: what structure to follow, how to adapt the language according to the recipient, what mistakes to avoid and what the Argentine regulations say. In the end we leave you a complete psychological report model to copy and adapt.

What a psychological report is and how it differs from the medical records

The psychological report is a professional document in which you communicate, in writing and to a particular recipient, the results of an evaluation or the state of a therapeutic process. It always responds to a request: someone requests it with a specific objective, and that objective defines what goes inside and what does not.

The most common confusion is to treat it as an extension of medical records. They are distinct documents with opposite logics:

Types of psychological report by recipient

The base structure is maintained, but the content, the level of detail and above all the language change according to who will read it.

School report

It is requested by the school, the guidance team or the parents for an inscription, an external companion or a curricular adaptation. It is read by teachers without clinical training: the language has to be descriptive and oriented to the functional (what the child can do, what it costs, what supports it needs in the classroom). The family dynamics and the session material do not take place here.

Judicial or expert report

When requested by a court, the requirement goes up: everything you affirm can be questioned by the parties, so every conclusion has to be based on what is evaluated and the methodology used. The expertise itself has its own rules that go beyond this guide, but the principle applies to any report that ends up in a file: maximum accuracy, zero speculation.

Labour Report

It appears in aptitude assessments, reincorporations or ART processes. The risk here is the use that an employer can give to the information: extreme data minimization. Inform about what was asked and nothing more.

Report for health insurance or private health plan

It is usually brief: it bases the continuity of treatment or the authorization of more sessions. Health insurance needs diagnosis, frequency and general evolution, never the content of the sessions.

Interconsultation report

Addressed to a psychiatrist, neurologist or other health professional, this is the only case where technical language is fully justified, because the reader has clinical training. However, communicate only what the colleague needs for his intervention.

The question that orders everything: who will read this and what do you need it for? I wrote for that person, for that purpose.

Structure of a psychological report, section by section

Beyond the type, a well-armed psychological report follows a recognizable structure:

1.

Full name, title, professional registration and contact details. Registration is not a detail: it is what enables the document before any institution.

2.

Full name, DNI, date of birth and age. Enough to identify who you're talking about, nothing more.

3. Reason for the report and who requests it

Two or three lines that frame everything that follows: who asked for the report, with what objective and in what context. For example: "This report is prepared at the request of School X, with the aim of providing information about the ongoing treatment process." This frame is your best defense: it makes clear that the content responds to a specific request and not to a spontaneous dissemination of clinical information.

4. Methodology

What you did to get to what you're going to say: number of interviews, period evaluated, techniques and instruments managed. This section gives weight to your conclusions: it's not the same as an interview impression as an evaluation of five encounters with specific techniques.

5. Diagnostic results and appreciation

The body of the report. I described what was observed and what was evaluated, ordered by areas if it helps the reading (cognitive, affective, binding). If you include a diagnosis, clarify the degree of certainty: "presumptive", "compatible with", "impressive". Diagnostic rotundity without sufficient foundation is one of the most expensive errors paid for.

6. Conclusions and suggestions

The synthesis that responds to the reason of the report. If the request was about a school support, the conclusion speaks of that. Suggestions have to be concrete and be within your purview: suggest a psychiatric interconsultation yes, indicate medication no.

7. Place, date and signature

Every report closes with place and date of issue, signature, clarification and registration. Without this, the document does not compromise anyone and therefore is worthless.

The Guiding Principle: Reporting Only Relevant

If you have a single idea of this guide, let it be this: in a psychological report it only goes the information relevant to the objective for which it is requested. What is not needed, does not go.

It is not just a good practice: it is a legal and ethical obligation based on three pillars:

• Act 25.326 on the Protection of Personal Data: health data are sensitive data, and the law requires that the information processed be adequate, relevant and not excessive in relation to its purpose. A school report with intimate details of the child's parents violates this principle in full.
• Professional secrecy: issuing a report is an exception limited to the duty of confidentiality, enabled by the patient's consent or by a court order. The exception covers the pertinent to the request, not everything you know. About its scope and limits we write in this guide on professional secrecy.
• FePRA's Code of Ethics: requires that reports be clear, accurate and rigorous, and that information shared with third parties be limited to what is necessary.

Before closing any report, I reread with this question: does each data contribute to the purpose of the order? What does not contribute, is deleted.

Patient consent

Except for a court order, do not issue a report without the patient knowing and accepting that you are going to do it. Ideally in writing, leaving record of three things: that authorizes the issuance of the report, to whom it will be delivered and for what purpose.

The patient is the holder of his health information and has the right to know what is said about him and to whom. In addition, documented consent protects you: if someone questions why you disclosed clinical information, you have the support of the express authorization of the holder of that data. If you work with informed consent from the beginning of treatment, you can include a general clause on reports and supplement it with a timely authorization for each issue.

In the case of children and adolescents, authorization is given by their legal representatives, without losing sight of the child ' s right to be informed according to his or her degree of maturity.

The language: technical but understandable

A psychological report is not a session note or academic paper. Some writing guidelines make a difference:

• I wrote for the recipient: if read by a teacher or a judge, the jargon does not communicate, obscures. Technicalities are justified only among colleagues.
• Described before you qualify: "There are difficulties in sustaining attention during the interview" reports; "it is a scattered child" tag. Valor judgments do not take place in a report.
• I distinguished the observed from the inferión: what you saw and what you interpret are different things and the text has to reflect it. "During the interviews he was withdrawn" is observation. "Which could be linked to the recent moving episode" is inference, and it is appropriate to present it as such.
• Matify diagnoses according to real certainty: "compatible with a picture of anxiety" is not professional weakness, it is precision. The firm statement remains for when the evaluation sustains it.
• Short Phrases, Active Voice, Zero Filling: The best report is understood at first reading.

What you sign commits you

Your signature turns the text into a document with consequences: everything that a signed report says can be used in a judicial process, an audit or a complaint to the professional college, for or against you.

That's why the rule is simple: don't sign anything you can't hold with your evaluation and your records in the medical records. If a lawyer asks a hearing where a conclusion came from, the answer has to be in your documentation, not in your memory.

Keep a copy of each report issued, with date and record of who it was delivered to, as part of the patient’s medical records. In Brauni the reports are generated in PDF with a digital verification code: any third party can verify that the document is authentic and was not altered after your signature, as we count in this note on digital verification of reports.

Frequent errors in drafting a psychological report

Copy and paste from other reports

The most tempting and most noticeable shortcut. Generic phrases that could apply to anyone, data from another patient that remained undelete, conclusions that are not connected to the described methodology. Whoever reads reports often detects recycling immediately, and your credibility resents.

Resounding diagnostics where presumption corresponds

To affirm "the patient has X disorder" after two interviews, without instruments to support him, is to be exposed free of charge. Use the conditional and presumption formulas when the evaluation does not enable more than that.

Think about people you didn't evaluate

The classic of reports in family conflicts: the patient talks about his ex-partner, and the report ends by stating that "the father presents violent traits", when you never evaluated him. You can record that the consultant refers to certain situations, making it clear that it is his account. Emitting clinical judgment on someone who never went through your clinical practice is a serious ethical misconduct and a frequent source of complaints.

Excess intimate data

Include session material, details of sexual life, third party information or background information that do not contribute to the purpose of the order. Each unnecessary data is a potential violation of the patient's privacy and the principle of relevance of the 25.326 Law.

Model psychological report for copying

We leave you an adaptable base template. Adjust to the type of report and consult with your professional college about the requirements of your jurisdiction.

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PSYCHOLOGICAL REPORT

Place and date: [City], ________________

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PROFESSIONAL DATA

• Name and surname: Lic. [Name and surname]
• professional license: M. P. / M. N. [Number]
• Professional contact: [Telephone / Email / Address]

CONSULTANT DATA

• Name and surname: [Name and surname]
• DNI: [Number]
• Date of birth: /____ - Age: [Age]

GROUNDS FOR THE REPORT

This report is prepared at the request of [person / institution requesting it], with the aim of [specific purpose of the order]. [the consultant / legal representatives] is authorized to issue and deliver it to [addressee].

METHODOLOGY

• Period evaluated/treatment: [From - to]
• Quantity of interviews: [Number and type]
• Technicals and instruments administered: [List interviews, tests, scales, techniques]

Results and diagnostic appreciation

[Description of what was observed and evaluated, sorted by areas if applicable. Distinguish what was observed from what was inferred. If a diagnosis is included, indicate the degree of certainty: presumptive, compatible with, confirmed by specific evaluation.]

Conclusions and suggestions

[Synthesis that responds to the reason for the report. Concrete suggestions, within professional competence.]

It is noted that the present report is prepared for the purposes requested and that its content is limited to information relevant to that purpose.

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Signature: _____________________

Clarification and registration: _____________________

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Frequently Asked Questions

Can the patient read your report?

Yes. The patient is the holder of his health information (Law 26.529) and has the right to access what is written about him. Beyond the law, it is good practice: to show him the report before handing him over avoids misunderstandings and strengthens confidence.

Can I refuse to make a report?

It depends on who asks. If requested by the patient or a third party with his permission, in principle it is appropriate to do so, although you can set reasonable deadlines and agree on the scope. If ordered by a judge, unjustified refusal can bring legal consequences. What you can always do is delimit the content: find out more about what you evaluated, not what you are being asked to speculate about.

How much do you charge for a psychological report?

It is an independent sessional benefit and it is appropriate to collect it as such: it takes time to write and carries with it legal responsibility. Many professional colleges publish guidance fees that include it: consult the gazetteer of your jurisdiction and agree the honorarium with the patient before writing.

Can I send the report by email or WhatsApp?

Carefully. The report contains sensitive data and the 25.326 Act obliges you to protect them in the shipment as well. If you send it digitally, let it be to the agreed recipient, in PDF and through a channel that you can document. Avoid groups and intermediaries that you will not control.

Summary

• The psychological report comes out of clinical practice and is read by third parties: the medical records records everything, the report only communicates the pertinent to the request.
• The recipient defines the language: descriptive and functional for schools, rigorous and informed for courts, technical only among colleagues.
• Minimum structure: professional and professional license data, consultant data, reason and applicant, methodology, results, conclusions, date and signature.
• Guiding principle: to report only what is relevant to the objective (Law 25.326, professional secrecy, Code of Ethics of FePRA). What is not necessary, does not go.
• Except for a court order, he issues reports with the patient's consent, knowing who he surrenders to and for what.
• I distinguished the observed from the inferión, nuanced the diagnoses according to the real certainty and never emitas clinical judgment on people you did not evaluate.
• Your signature commits you: keep a copy of each report in your medical records, along with the authorization and the record of delivery.