The overall purpose of most clinical evaluations is a well-integrated and coherent report that addresses the referral question and other critical issues
The content and organization of any evaluation are largely dependent upon the referral source. Reports should differ in sophistication depending on the audience that they are written for.
o Clinicians may make explicit statements about the certitude of a conclusion (e.g., while the test results suggest…these results should be viewed as preliminary)
o Clinicians may offer explicit cautions about the accuracy of clinical methods (e.g., while the best measure available was used, the PCL-R, has not been explicitly validated with Hispanic women and so these results should be viewed as tentative)
o Clinicians can offer several alternatives for a particular finding; the presentation of alternatives minimizes the possibility that any one interpretation is accepted as conclusive
o The final alternative is to omit the finding altogether, if it is peripheral to the referral issue and nonessential to understanding the patient
Melton et al. have set out four general guidelines for report writing.
(1) separate facts from inferences
(2) stay within the scope of the referral question
(3) avoid information over and under kill
(4) minimize clinical jargon
Weiner also talks about the need to be clear, relevant, informative, and defensible.
Indicate at the beginning of your report the issue that was examined (the referral questions) and the sources of information that were used in the evaluation. Also prudent to include a list of those materials that were requested and that might help in this evaluation but which were unavailable or not provided. Indicate that they were requested and then whatever the particular circumstances are with respect to each information source (e.g., unavailable, records destroyed, records not provided by other side, etc).
Write reports in ordinary language that is easy to understand. Include the reader in your decision making process (i.e., walk to reader through your thinking). Weiner recommends using unstilted and uncomplicated language that will be comfortable to repeat on the witness stand and comprehensible to their audience and that will give little opportunity for cross-examining attorneys to badger with questions about what you mean.
Describe 'people' rather than psychological 'processes'.
Address and attempt to answer the referral question
Provide a distillate of those features of the individual that bear directly on the issues in the case and the client's questions about them.
Be sure to clarify the referral question with the retaining client before beginning the evaluation
(1) make sure you have the knowledge and training to be able to conduct the evaluation
(2) to ensure that proper topics are probed during the evaluation
(3) to determine the appropriate notification to give the evaluee
(4) to determine if there are any hidden agendas and to deal with these issues up front
(5) to avoid any misunderstandings or miscommunications
(6) to inform the retaining party of any particularly relevant information such as the clinician's stance on using ultimate issue testimony.
Psychologists should be familiar with case law and statutes and can increase relevance by integrating such knowledge into their reports, especially with respect to appropriate terminology.
Reports should be written in an informative manner that educates the audience.
This informational objective can usually be achieved by relating psychological data and impressions to benchmarks that the audience will recognize.
Psychological terms can be defined for the reader when they are first introduced into the report.
Backing up conclusions and opinions with relevant and important information will educate the reader.
Psychologists should write their reports as if the opposing attorney is sitting on their shoulder.
Psychologists should stick to more solid ground by describing how the person he or she evaluated resemble certain types of people who have had certain types of experiences, rather than categorize their evaluees as being a particular type pf person who has had a particular type of experience.
Relative statements about people usually create fewer difficulties for forensic consultants than absolute statements. Best to couch statements in relativistic (or conditional) terms such as more or less, etc.
Avoid black and white thinking and writing.
Avoid writing statements that rule out conditions or events. Can emphasize what their findings demonstrate as probably being present rather than focusing on negative findings.
In those circumstances where reporting negative findings is absolutely called for, psychologists should still exercise caution in drawing conclusions from their findings.
Avoid including illustrative test responses in reports. This applies to psychological tests rather than FAIs where it might be very appropriate to include specific answers to inquiries. An individual response to a psychological test by itself means nothing--it is the entire pattern of responses and their component scales that are interpretable.
I prefer to speak to the penultimate legal issue rather than the ultimate legal issue. Always wise to include a statement about your opinions being advisory in nature and a reminder that the court is to decide the ultimate legal issue, not the forensic psychologist.