WHT Law

Qualities of a Good Clinical Report

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Qualities of a Good Clinical Report

* This memo was drafted in response to an inquiry from a clinical psychologist who requested information about the “essential characteristics of an effective psychological evaluation.”

I have several requirements for reports, and in fact have been teaching these principles in report writing for the past 20 years to UIC medical school doctors who want to specialize in child and adolescent psychiatry. The principles apply to ANY clinical report, not just psychological reports. I admit to a bias that I have to be able to utilize the report as a basis for motivating sometimes reluctant agencies (like school districts, state agencies, etc.) to pay for services that a patient/client might need.

Qualities are as follows:

  • The report must flow logically, be written in excellent prose, and clinical findings must be the basis for all recommendations presented;
  • Ideally, the report should contain as a first section a comprehensive review of all clinical material that preceded the report;
  • After a review of prior evaluations, there should be an introduction to tests or evals chosen, in light of prior testing efforts, and a highlighting of any gaps, if any, that the current examiner found in prior materials;
  • If the examiner uses a testing vehicle not commonly used, it’s a good idea to educate the reader, in simple terms, as to the qualities the test is designed to evaluate, and the reason the examiner is selecting this particular evaluative tool;
  • The recommendations section must contain recommendations! My pet peeve is a wishy washy “Recommendations will await the team meeting” or some such nonsense. The examiner must come right out and say what the patient needs, with as much specificity as possible, and relate the recommendations to the clinician’s findings. To me, a report is worthless if there is not a concrete, detailed series of recommendations.
  • It is not required, but usually a good idea, to examine what will likely happen to the patient if the recommendations are NOT followed – this is required where serious harm or death could occur;
  • The examiner must be willing to leave the office and accompany his or her report to the meeting that will usually be held to consider it, as it’s much easier to discount the conclusions of a professional who isn’t there;
  • If the report is written for a specific purpose, such as to convince a school district to declare a pupil eligible for ED special education services, the examiner must be conversant with the definitions used by the particular system appealed to. For example, the special education law has a different definition of “Emotionally Disturbed” than does the DSM. The examiner must know definitions from other systems (if applicable) prior to drafting a report.