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Elements of Best Practice Psychological Reports


1. The credentials of the evaluator(s).
Credible psychological reports that are universally accepted by Institutions of Learning, the Court system, and professional peers are provided by licensed, doctoral-level professionals who have undergone appropriate and comprehensive education at an accredited institution. They have relevant training and experience to the presenting problem, and have no conflicts of interest (e.g. personal relationship) with the individual being evaluated.  

2. A thorough and relevant history.
A thorough and Relevant History reviews development and early milestones, history of learning problems, familial history, interpersonal relationships, history of medical problems, medication history, and psychosocial factors that impact current functioning.  Histories should also include:  Academic and vocational history (success and failure), emotional functioning and psychiatric problems, any legal problems, and substance abuse.     

3. A description of current and past accommodations, services and/or medications.
Comprehensive documentation will include a description of both current and past medications, auxiliary aids, assistive devices, support services, and accommodations, including their effectiveness in ameliorating functional impacts of the disability. While accommodations provided in another setting are not binding on the current institution, they may provide insight in making current decisions.  Previous services are likely derived from previous evaluations which should also be reported on in the current report to evaluate the evolution of the disorder.

4. A description of the diagnostic methodology used.
Documentation includes a description of the diagnostic criteria, evaluation methods, procedures, tests and dates of administration, as well as a clinical narrative, observation, and specific results. Where appropriate to the nature of the disability, having both summary data and specific test scores (with the norming population identified) within the report is recommended.

Diagnostic methods that are congruent with the particular disability and current professional practices in the field are recommended. Methods may include formal instruments, structured interview protocols, performance observations and unstructured interviews. If results from informal, non-standardized or less common methods of evaluation are reported, an explanation of their role and significance in the diagnostic process will strengthen their value in providing useful information.

5. A description of the current functional limitations
Information on how a disabling condition(s) currently impacts the individual provides useful information for both establishing a disability and identifying possible accommodations. A combination of the results of formal evaluation procedures, clinical narrative, and the individual’s self report is the most comprehensive approach to fully documenting impact. The best quality documentation is thorough enough to demonstrate whether and how a major life activity is substantially limited by providing a clear sense of the severity, frequency and pervasiveness of the condition(s).

While relatively recent documentation is recommended in most circumstances, common sense and discretion in accepting older documentation of conditions that are permanent or non-varying is recommended. Likewise, changing conditions and/or changes in how the condition impacts the individual brought on by growth and development may warrant more frequent updates in order to provide an accurate picture. It is important to remember that documentation is not time-bound; the need for recent documentation depends on the facts and circumstances of the individual’s condition.

6. A formulation of the progression or stability of the disability
It is helpful when documentation provides information on the development, evolution, and expected changes in the functional impact of the disability over time and context. Information on the cyclical or episodic nature of the disability and known or suspected environmental triggers to episodes provides opportunities to anticipate and plan for varying functional impacts. If the condition is not stable, information on interventions (including the individual’s own strategies) for exacerbations and recommended timelines for re-evaluation are most helpful.

7. A diagnostic statement and Formulation
Documentation should include a clear diagnostic statement. A formulation is included that describes how the condition was diagnosed, provides information on the functional impact, and details the typical progression or prognosis of the condition. Diagnostic codes from the Diagnostic Statistical Manual of the American Psychiatric Association (DSM-IV-TR) should be used.

8. Recommendations for accommodations, adaptive devices, assistive services, compensatory strategies, and/or support services such as Residential Treatment, Psychiatry or Outpatient Therapies.
Recommendations are specific and individualized.  Recommendations are not disorder specific but specific to the clients needs.  While there are general recommendations that are helpful for specific conditions which may be applied generally, every clients has a unique learning style and personality pattern that should be addressed through customizing recommendations.   Recommendations should be justified and where possible, evidence-based.

These dimensions of good documentation discussed are determined to be the best practices in Psychological Assessment.  
At PsychTesting, these are the standards for every report.  

This approach will enhance the reliability that should be required of all Psychological Testing and provide all stakeholders (clients, parents, and professionals) with the information they need to assist students in establishing eligibility for services and receiving appropriate accommodations.


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