Structuring Behavioral Reports
How can the mass of demographic information, behavioral description, and test results now be woven together to make a vivid and accurate picture of your client, and above all a picture that will answer the questions that your referral source has put to you?
These questions may be narrow and specific (e.g., if an ophthalmologist needs more information about the reading difficulties of a brain injured client), or broad and wide-ranging (e.g., a psychiatrist asks about personality functioning, dangerousness, and optimum treatment). If a rehabilitation team makes the referral, they may relate to the capacity to learn and retain new information in a variety of different modalities. A report for the primary caregivers and extended family will deal with prognostic and day-to-day management issues.
To complicate matters even further, the "discourse register" of the report -- to borrow a term from chapter 7 -- is very different for health care professionals on the one hand and lay readers on the other. Of course, even for professionals, it is always a good idea to explain in a sentence or two the content of each of the tests and what it measures: You cannot expect neurosurgeons or physiatrists to be familiar with Trails A and B or the AVLT (for further suggestions on this point, see "Test Performance" later). For caregivers and the family, technical jargon should be replaced by simple English without talking down to your readers.
As a result, reports vary enormously in focus, length, vocabulary, tone, and the stringency of the argumentation that leads to the given conclusions. What I have chosen to do is to describe the structure and content of a forensic report, which is more comprehensive, more lucidly written, and more stringently argued -- because it will be more rigorously tested -- than