Report Writing Flashcards
Full evaluation is not complete until
Information has been organized, synthesized, and integrated
Delivery
Written report & oral summary
Generally, the written report should convey
- Background information
- Findings of assessments
- Clinical impressions
- Specific recommendations
The importance of reports
To document the current ability level of the child
* Areas of strength and weaknesses
* Includes information from parents, teachers, guardians
To communicate recommendations and / or interventions
* To report to another psychologist, a school counselor, teacher, parent
* Given as a resource to help the child (socially, behaviorally, emotionally, academically)
To provide a basis of support for the child
* Reports are weighted heavily in decision-making to aid a child in school
* Helps with development of IEP (individualized education plans)
An effective report should:
- Utilize formation provided by all key sources
- Organize information for future use
- Synthesize and integrate information about the child
Intake process
This is an initial source of information
Typically filled out by a parent or guardian at the time of intake
* Questionnaires
* Includes large amounts of data
Could include interviews with the parent or child
* At the discretion of the assessor
* Depends on training, purpose of assessment, etc.
Intake process
Information includes:
Basic background information
Developmental history
Medical history
Family information
Parent personal data
School referral information
Intake process
Information includes..
Basic background information
Contact
* Presenting problem
Intake process
Information includes..
Developmental history
Behaviours during infancy
* Pregnancy information
* Age of behavioural development
Intake process
Information includes..
Medical history
Child’s medical history
* Family medical history
Intake process
Information includes:
Family information
The child’s family unit
* Stress within the family
Intake process
Information includes:
Parent personal data
Educational history
* Work history
* Personal characteristics
* Medical / health status
Intake process
Information includes
School referral information
Teacher / principal report’s
* Special education program
* School psychologist reports
Preparing the report
Consideration to who the target audience is
Ensure that it is readable by non-professionals
Key elements:
* Concise
* Clear
* Objective
* Accurate
Content of the report
- Identifying information
- Assessment instruments
- Reason for referral
- Background information
- Observations during the assessment
- Assessment results and clinical impressions
- Recommendations
- Summary
IARB OARS
Content of the report
Identifying information
Name: _____________
Date of birth: ________
Sex: M / F
Chronological age: __ years __ months __ days
Dates of the assessment: _ _ / _ _ / _ _ _ _
Date of report: _ _ / _ _ / _ _ _ _
Institution / agency: ___________________
Your contact information: _______________
Content of the report
Assessment Instruments
List of instruments
* Quick reference of tests that were used in the assessment
Wechsler Intelligence Scale for Children–IV (WISC-IV)
Peabody Picture Vocabulary Test–IV (PPVT-IV)
Content of the report
Reason for Referral
Synopsis of the reason for the referral
* Who initiated the referral (relationship / position / affiliation)
* What was the purpose of the assessment (as requested)
* Question and concerns that were raised by the referral source
* A brief summary of the presenting issues or behaviours
Content of the report
Background information
- Developmental milestones / history
- Medical history & medical reports (*cite source & date)
- Educational history
- Current grade level in school
- Any special programming in school
- Present level of academic functioning
- Information from interviews with parents / teachers
- Data about past gathered from your interview of the child
- Information from previous psychological or psychiatric assessment
- Previous interventions / outcomes regarding the referral questions
Current family situation - Family constellation / relevant family history
- Information on parent occupations and education
- Parent views on discipline, child’s responsibilities, and parent involvement with the child
- Social interactions / peer relationships
- Teachers’ and parents’ observations of child’s behaviour and attitudes
Access to past records – requires parent / guardian permission through release-ofinformation forms
Personal Health Information Protection Act 2004
* “Request to access personal health information form”
* Governs the manner in which personal health information may be collected, used,
and disclosed within the health sector
* Safeguards the child’s personal information
Data also collected through interviews
* Assess the quality of information provided
o e.g. was the parent cooperative, engaged, supportive, concerned, hostile, detailed &
thorough, vague, uncertain?
* Assess gaps and inconsistencies in information
* Organization of information à begin with the parent or referral source
Content of the report
Observations
Carefully describe the child’s behaviour during the evaluation
Best written by describing the presence vs. absence of a behaviour
* e.g. “the child was not hyperactive” vs. ”the child was quiet and calm” / “the child stayed on task”
Include observations important for the assessment
Use descriptions of the behaviour as opposed to interpretations
* In some instances, it may be useful to describe the behaviour followed by an interpretation
* e.g. child tapping feet
Content of the report
Assessment Results and Clinical Impressions
Need to go beyond just the findings and interpret their meaning
* Begin by qualifying if the assessment is viewed as valid & reliable
* Cite any concerns à that test results do not clearly reflect the child’s abilities
* Identify instruments, test scores, percentile ranks, and confidence intervals
* Strengths and weaknesses
* Describes significant problems, indications of psychopathology, signs of
exceptionality, creativity, giftedness
* Note interrelationships across findings
* Implications of the assessment findings and any diagnostic impressions
