Discussing old testing results/data in reports

[BuckeyeLove]

Hey all,
Wanted to throw out a question that has been bugging me as of late, as I've gotten way more variability in the responses than I thought I would initially. Let's say you're evaluating someone, have access to old evaluations (as we often do), and want to provide some information in your report regarding testing completed in that eval. What do you choose to include regarding said testing? Summary of the results/approach to testing? Actual data (i.e., scaled scores, percentiles, etc.)? My philosophy has always been to tread lightly with this as I did not complete the old evaluation and testing, but I've gotten some feedback from people lately that has been somewhat contradictory to this.
As always, any thoughts are most appreciated!

---

Members don't see this ad.

 

[WisNeuro]

Usually just the summary for me, though, I will occasionally discuss specific test scores if I need to document something (e.g., stability or decline in a domain).

 

[LadyHalcyon]

I do a summary of records reviewed. I will typically highlight relevant test results, as applicable.

Sent from my SM-G973U using Tapatalk

 

[AcronymAllergy]

I nearly always include information on prior testing in my reports. Like folks above, I'll usually do a summary of findings and impressions, which is based on what the previous provider wrote. If I can see the scores and/or might not necessarily agree with the impression, I may provide more information on the scores themselves.

And like WisNeuro, in my summary and impressions, if I have access to the data, I'll typically discuss changes/stability over time. If I don't have access to the data (e.g., if I only have qualitative descriptors), I may try to make very broad approximations of change/stability, but will state the limitations of such in my report.

 

[ClinicalABA]

I highlight general test results in the developmental summary section- e.g., “received an autism diagnosis”; “demonstrated average receptive and expressive language abilities”. I may give more detail from previous testing in the specific results sections. For example, in the “Cognitive” section, I might say “ client demonstrated average cognitive abilities during the current assessment (compared with borderline abilities during the previous assessment).

More often than not, however, I did the previous testing.

 

[SportsNeuroPsych]

I always reference it and make a summary statement of some sorts. I also often directly quote scores (if available) or impressions as well and how that compares to the evaluation that I conduct with them but I am not necessarily going to throw the other provider under the bus if I do not agree. I feel like if you have access to an old report and you don't include it in your review of records, it is somewhat negligent.

 

[jdawg2017]

I guess to contrary to this is within sites I have trained at if they prior evaluation was completed by someone from within the site and the whole report is already in their chart I almost always have been trained to include that data in a new, updated data table, indicating which data is which for those wishing to make an easy quantitative comparison. This is a rare case, but has happened to me at least a dozen times throughout my training. Of course I don’t make any claims about prior testing, but use it for comparison to what we found in the current eval.

 

[R. Matey]

I guess to contrary to this is within sites I have trained at if they prior evaluation was completed by someone from within the site and the whole report is already in their chart I almost always have been trained to include that data in a new, updated data table, indicating which data is which for those wishing to make an easy quantitative comparison. This is a rare case, but has happened to me at least a dozen times throughout my training. Of course I don’t make any claims about prior testing, but use it for comparison to what we found in the current eval.

I was trained to do it this way too, but it's been rare for me to see it in other evals.

 

[AbnormalPsych]

I guess to contrary to this is within sites I have trained at if they prior evaluation was completed by someone from within the site and the whole report is already in their chart I almost always have been trained to include that data in a new, updated data table, indicating which data is which for those wishing to make an easy quantitative comparison. This is a rare case, but has happened to me at least a dozen times throughout my training. Of course I don’t make any claims about prior testing, but use it for comparison to what we found in the current eval.

I do this as well if past report data is from my own medical system. If it is from another agency or provider I typically just write a brief verbal summary of it in my background section. As appropriate (e.g., substantial decline in an area) I will be more specific in comparing to prior records in the impressions section.