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
Identification and Presenting Problem: Brief description of the client and the reason for assessment, including referral questions and client’s questions
Relevant History: Identify and describe sources of information for all aspects of history
History of present illness
Habit/Substance use history
Cultural and spiritual history
Hobbies, leisure time pursuits
Medical history including medications currently prescribed
Psychiatric history including medications currently prescribed
Review of records not reviewed in other sections
Behavioral Observations: Clientâ€™s distinguishing features, including use of prosthetic devises/aids. Clientâ€™s primary language and language of assessment. Self-reported level of physical comfort during the examination: any medications or chemical substances taken; corrective devices worn; 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.
Tests and Procedures Administered: List all the tests by their full name
Test Results: Combine the results of particular tests into coherent assessment of the domains of functioning. Include interpretation of data and standard scores and percentiles
Overall Intellectual Functioning
Language and Verbal Abilities
Sensory Perception and Motor Functioning
Attention, Concentration, & Information Processing
Short-Term and Working Memory
Learning, Long-Term Memory
Discussion: Summarize the history, behavioral observations, and test results into a coherent diagnostic picture. Your goal is to answer the clientâ€™s question, referral question, provide evidence for your diagnosis, and to substantiate your recommendations.
DSM Diagnosis: Each diagnosis should be justified by specific, direct reference to exact DSM criteria.
Recommendations: Concrete recommendations for procedures and treatment.