How to Write a Psychological Assessment Report
The National Institute of Mental Health reports that one in four adults suffers from some form of mental illness. While some mental illnesses do not severely affect the sufferer's daily life, others have a significant effect. When diagnosing a mental illness and determining an appropriate course of treatment, mental health practitioners commonly compose a psychological assessment report.
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Instructions
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List the patient name, case number and dates of your assessment. The top of your report should include all identifying information so that the report can be easily filed and referenced later. It should also include the date so that your report can be placed in the proper order when combined with past and future assessment reports.
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Include information about the facility at which the report was compiled. List the name, address and phone number of the facility. By including this information you allow future report viewers to contact the facility if they should encounter a problem or have a question.
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Explain the reason for the evaluation. Write several sentences explaining why the evaluation was deemed necessary. If the decision to evaluate was based upon a specific incident, describe the incident clearly.
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Include background information about the patient. List as much information as you know about the patient's history. This information can be helpful to future observers, as it makes it easier for them to establish a pattern of behavior for the patient in question.
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Describe the assessment procedures. If you are using a well-established assessment procedure, list the procedure by name and include some details about the assessment. If the assessment is lesser known, be more specific in your explanation. Also, include any ways in which your assessment process differed from the norm so that others can replicate the assessment.
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Report your observations of the patient's mental status during the assessment. If the patient seemed overly excited, withdrawn, excessively sad or exhibited any emotion that deviated from the norm during the assessment, describe it in your report.
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List the results of the assessment. If the results include numbered values, clearly explain what each numbered value means, or include a graph or diagram for users to reference as they interpret the test results.
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Make a recommendation based upon the findings of the assessment. Assessments are normally performed for prescriptive reasons. Explain what your findings indicate and how this information should be used to treat the patient in question.
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References
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