Nature and Formal Structure

Definition and Purpose of the Report

The psychological report is defined as a medico-legal, written document, in which information is collected in a thorough manner with the primary purpose of transmitting it to a third party.

This third party may be a neurologist, psychiatrist, an educational institution or another colleague, so its writing is not typically intended for the patient's personal use, but for an interconsultation or institutional requirement.

It should be submitted in hard copy (on computer), never handwritten, and is governed by principles of accuracy, objectivity and confidentiality.

Although it is confidential, it is less so than the clinical history, since the report filters and selects the pertinent information for the addressee, excluding intimate details of the psychotherapeutic process that are not relevant to the objective of the report.

General Structure and Identification Data

The standard structure accepted by the profession includes several mandatory sections: Identification Data, Reason for Consultation, Instruments Applied, General Case Information, Results, Areas Evaluated, Diagnostic Impression, Conclusions and Recommendations.

In the identification data it is crucial to be exhaustive; if a child is being evaluated, not only his or her data (name, age, schooling) but also those of the parents or legal representatives should be included.

Contact data, occupation and with whom the patient lives should also be recorded, ensuring a complete sociodemographic picture before proceeding to the clinical content.

Summary

The psychological report is a written medico-legal document, designed to transmit selected information to a third party, such as physicians or institutions, and should always be delivered in hard copy to ensure legibility.

Unlike the clinical history, its confidentiality is relative, as it filters intimate details of the therapeutic process, including only information relevant to the recipient and the purpose of the report.

The structure must follow a rigorous guild standard that includes exhaustive identification data of the patient and his or her representatives, ensuring a complete sociodemographic record before presenting the clinical content.