A Functional Guide to Report Construction

I. Conducting a Mental Health Evaluation

1. Beginning and Ending the Interview

2. Mental Status Evaluation Questions/Tasks

3. Questions about Signs, Symptoms, and Other Behavior Patterns

II. Standard Terms and Statements for Wording Psychological Reports

A. Introducing the Report

4. Beginning the Report: Preliminary Information

5. Referral Reasons

6. Background Information and History

B. The Person in the Evaluation

7. Behavioral Observations

8. Responses to Aspects of the Examination

9. Presentation of Self

10. Emotional/Affective Symptoms and Disorders

11. Cognition and Mental Status

12. Abnormal Signs, Symptoms, and Syndromes

13. Personality Patterns

C. The Person in the Environment

14. Activities of Daily Living

15. Social/Community Functioning

16. Couple and Family Relationships

17. Vocational/Academic Skills

18. Recreational Functioning

19. Other Specialized Evaluations

D. Completing the Report

20. Summary of Findings and Conclusions

21. Diagnostic Statement/Impression

22. Recommendations

23. Prognostic Statements

24. Closing Statements

III. Useful Resources

25. Treatment Planning and Treatment Plan Formats

26. Formats for Reports, Evaluations, and Summaries

27. Treatments for Specific Disorders and Concerns

28. Listing of Common Psychiatric and Psychoactive Drugs

29. Psychiatric Masquerade of Medical Conditions

Appendices

A. Abbreviations in Common Use

B. Annotated Readings in Assessment, Interviewing, and Report Writing

Feedback Solicitation Form

References

About the Clinician's Electronic Thesaurus, Version 7.0