CSAD 330 Diagnostic Report Writing

for exam 2

format of diagnostic report

subjective, objective, assessment, and plan (a soap model)

subjective part of diagnostic report

summarizes relevant information from the review of documentation and interview; involves any identifying information about the client like age, medical history, impact of impairment, etc.

objective part of diagnostic report

involves data from testing completed during the evaluation (including observation and standardized/nonstandardized tests)

assessment part of diagnostic report

integrates the findings of the subjective and objective sections to make a decision about disability

plan part of diagnostic report

provides recommendations for the client’s next steps

verb tense in reports

use past-tense for the subjective and objective parts and present tense for the assessment and plan parts

verb choice in reports

verbs need to match the subject; copular verbs are preferred when describing test scores

word choice in reports

words need to be professional but not professional language (unless defined/described)

what to include when writing test results

test name, what it assesses, the performance/standard score (include confidence interval and percentile rank), specific examples of the client’s performance, and the cut score and whether the client was similar to those with X disorder or similar to those without X disorder