Removing Information from Psychological Report

[future_dr.schoolpsych]

At my site (a university clinic), we are currently dealing with a parent that is insistent that a previous ADHD diagnosis and medication details be withheld from the final psychological evaluation report. Our evaluation does not support the current diagnosis. My supervisors and I have been torn about the ethical and legal implications of this. I’m looking for feedback on whether or not this is appropriate and how to best handle this situation from those with more experience.

Thank you!

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[psych.meout]

At my site (a university clinic), we are currently dealing with a parent that is insistent that a previous ADHD diagnosis and medication details be withheld from the final psychological evaluation report. Our evaluation does not support the current diagnosis. My supervisors and I have been torn about the ethical and legal implications of this. I’m looking for feedback on whether or not this is appropriate and how to best handle this situation from those with more experience.

Thank you!

Was reassessing the ADHD part of the referral question and evaluation?

 

[PsyDr]

You cannot legally remove information from a finished report. You can put forward an amendment.


However, you should not change your professional opinion because someone is unhappy. If that was how the profession worked all forensic work would be nullified.

 

[erg923]

At my site (a university clinic), we are currently dealing with a parent that is insistent that a previous ADHD diagnosis and medication details be withheld from the final psychological evaluation report. Our evaluation does not support the current diagnosis. My supervisors and I have been torn about the ethical and legal implications of this. I’m looking for feedback on whether or not this is appropriate and how to best handle this situation from those with more experience.

Thank you!

If it's true, it's true. If it's not, its not. Best place to start, obviously.

If it's true, it's relevant. It's a psychological evaluation after all, not a fiction novel.

 

[LadyHalcyon]

At my site (a university clinic), we are currently dealing with a parent that is insistent that a previous ADHD diagnosis and medication details be withheld from the final psychological evaluation report. Our evaluation does not support the current diagnosis. My supervisors and I have been torn about the ethical and legal implications of this. I’m looking for feedback on whether or not this is appropriate and how to best handle this situation from those with more experience.

Thank you!

What is the referral question and who is the report for? The closest I have come to dealing with something like that was when working at a private practice that served high ses clients. The parent who present for the clinical interview asked for information to be removed from the background section. She stated the information was incorrect (although I reviewed my notes and I'm sure she said what I wrote). My guess is she didn't want her husband to see what she had said. I made the change but I would have not removed correct, psychologically relevant information

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[Justanothergrad]

I can't think of a single reason to exclude that information from the evaluation if it is correct and relevant. An unhappy parent isn't a reason to change your professional judgement and doing so has ethical implications.

 

[smalltownpsych]

It seems that others are reading this in a different way from me. If you are asking about whether or not to leave off information from history as opposed to testing results. That is not the same as leaving out testing results. Obviously, not all information from history is included in a report, we tend to put in the general demographic information and the relevant history. In my mind, relevant would be the key word. In a psychological assessment report, I would think that past medications and past diagnoses would be more likely to be relevant. If the referral question was to rule out ADHD, then it would make sense that this prior information would be relevant. If it were me trying to make this decision, I would contact my insurance for a risk management consultation especially since this has some fairly direct legal implications.

 

[WisNeuro]

If you are writing a comprehensive report about psychological functioning, psych history is directly relevant. Leaving parts of it out intentionally, is sometimes unethical at worst, and makes you look amateurish at best. Either you write the report with relevant information included, or you could just not write the report at all in some instances. My reports are all done before I ever deliver feedback, so there is no real chance for someone to dispute until it's a part of the record.

 

[smalltownpsych]

This case has other ethical questions tied to it as well which might even be more pertinent. Why are the parents involved? If they are a U student, then they are typically of legal age. Also, why is there a referral for a psych evaluation if they don't want documentation about diagnosis. Who is the patient or client and who is paying for the eval and why? Also, it brings up one of my own areas of concern and that is the increasing use of psych records to potentially damage our patients down the road.