Psychodiagnostic Report Outline
Please, put this disclaimer at the top of your report: This report is confidential. Due to the presence of highly specialized information, it should only be interpreted by a qualified professional who received appropriate training in administration and interpretation of the psychological and neuropsychological tests used to generate this report. Please, be aware that not all mental health professionals have the appropriate training and experience.
All testing reports will have unique characteristics as symptom complexity, life history, synergistic medical conditions, etc. will create the need to elaborate or conversely, diminish in scope, aspects of the report. The following basic structure is suggested for all reports:
Header: Name, Date of Birth, Age, Ethnicity/Language, Parents (if applicable), Placement, Education, Occupation, Handedness, Dates of Examination, Date of Report, Examiners
I. Identification and Presenting Problem: Brief description of the client and the reason for assessment, including referral source and precise referral questions.
II. Relevant History: Identify and describe sources of information for all aspects of history.
1.History of present illness.
2.Social/family history.
3.Cultural history and spiritual beliefs.
4.Educational history.
5.Work history.
6.Legal history.
7.Military history.
8.Habit/Substance use history.
9.Hobbies, leisure time pursuits.
10.Medical history including medications currently prescribed.
11.Psychiatric history including medications currently prescribed.
12.Review of records not reviewed in other sections.
III. Behavioral Observations: Client’s distinguishing features, including use of prosthetic devises/aids. Client’s primary language and language of assessment. Self-reported level of physical comfort during the examination, any medications/substances taken, complaints, if any. Mental Status Exam. Behavior during testing: problem-solving approach, level of cooperation and effort, anxiety. Validity of current testing (based on observations during testing, validity scales, and malingering tests, if any). Include description of efforts made to accommodate testing conditions to specific needs of the client and caveats about possible inaccuracies due to language, culture, education, sensory deficits, and tests or norm deficiencies at the end of this section.
IV. Tests and Procedures Administered: List all the tests by their full name.
V. Test Results: Combine the results of particular tests into coherent assessment of the domains of functioning. Include interpretation of data and ranges and/or percentiles.
1.Overall Intellectual/Cognitive Functioning.
2.Attention/Concentration.
3.Language.
4.Visual-Spatial and Motor Functioning.
5.Memory and Learning.
6.Abstract Reasoning.
7.Emotional/Interpersonal/Adaptive Functioning.
VI. Discussion: Summarize the history, cultural factors, behavioral observations, and test results into a coherent diagnostic picture. Consider DSM-IV Cultural Formulation as part of your overall formulation here. Your goal is to provide evidence for your diagnosis and to substantiate your recommendations. Each diagnosis should be justified by specific, direct reference to exact DSM-IV criteria. Address referral questions here. Detailed instructions and an example of case formulation
VII. DSM-IV Diagnosis: Provide codes and diagnoses on all five axes.
VIII. Recommendations: Concrete recommendations for procedures and treatment.
