Discussing assessment results with patients

Once the patient has completed their assessments, it's important to take time during your sessions together to discuss their results. These discussions can help establish the patient's goals for therapy, allow for more insights into their progress, and establish a better therapeutic alliance. This article will walk you through how to weave progress measurement into your practice.

Here are some tips for discussing assessment results with your patients during a therapy session:

  • At the start of the session, review the patient's results and highlight any items that might have jumped out for both of you. Did the client think the assessments were helpful?  Why or why not?  Look at the individual questions as well. They can provide additional insight on what is going on and highlight discrepancies (what the client scored versus what is being reported in session). 
  • As you plan and establish goals for therapy, identify which assessments can reliably measure and track these goals. If goals change, do you need to remove or add additional assessments?
  • Do you know what is important to the patient versus what you might consider clinically important? How do you reconcile this with the patient and come to an agreement?
  • If there has been a shift in the symptoms the patient is reporting take time to discuss these results with the client to better understand what could have caused the shift. You can add an event note to your client's results graph to keep a record of the details around the shift. These types of notes are visible to both you and the client.
  • Be prepared to discuss suicidality. Patient's may not disclose that they are feeling suicidal during a session, but may feel more comfortable disclosing this in an assessment. 
  • Take time to discuss the therapeutic alliance by reading through the questions in the BR-WAI assessment to see if there are any areas that may need to be addressed.
  • Consider assigning the BR-WAI within the first 2-3 sessions to help gather an initial baseline of the patient's feelings particularly about their goals and the bond they feel with you. 

Next Article: Use event notes to add context

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