AI for Report Writing: Record Reviews

As testing psychologists, it can take us hours to review and summarize prior evaluations, report cards, progress notes, IEPs, and so forth.

I have always found reviewing these records extremely helpful for my assessment, but summarizing them for the report would take forever.

Until now.

Efficient Record Reviews

AI is an incredibly helpful tool for summarizing long, complex documents and translating them into parent-friendly language.

While AI is not a substitute for our clinical analysis, I’ve found it exceedingly helpful for capturing the main take homes from piles of documents in a way that parents often find even more helpful than the original document.

In other words, AI not only makes these write-ups more efficient, but also easier and more helpful for those reading the report. 

Here are a few ways I’ve been using AI to help with my record reviews.  I hope they’re helpful to your practice!

Note: Since we are working with client information, I urge you to use a HIPAA or FERPA-compliant AI tool such as Bastion, NoteZap, or School Psych AI for any of the ideas below.

Before You Begin…

Read the records!

AI is your co-pilot.  Not auto-pilot.  The quality of your output will depend on your ability to judge how well it pulled out the key points and captured the essence of the child you are assessing.  

Do not skip reading the documents themselves!

Option 1: Upload the document

For much of my work, I have found BastionGPT to be the most helpful AI because it is HIPAA-compliant and designed for medical professionals.

Recently, I discovered that Bastion now has the capability of securely uploading PDFs!

Click the attachment icon next to the chat box and upload the record you wish to summarize. 

Give Bastion a little bit of context about the document, and then ask it to create a summary using a prompt like this:

“This document is the child’s Occupational Therapy progress notes.  Please create a summary of the notes, using parent-friendly language.”

For example, here is what Bastion created from an OT report for Regina:

Regina’s occupational therapy evaluation in February 2024 found that Regina has some challenges with fine motor skills, like picking up small objects. She also seems to be seeking sensory experiences, which is evident in behaviors like rocking her body, touching things around her, and asking for tight hugs.

Regina also seems to have a bit of trouble understanding where her body is in space and following instructions that involve multiple steps. She has increased sensitivities to sight, sound, and touch.

The Occupational Therapist recommended the she receive weekly services.

Option 2: Ask AI to Summarize Your Notes

If, like me, you find it helpful to take notes as you review the records, you can paste your notes into the AI platform. 

Your notes do not have to be in full sentences or organized in any way.  You can ask the AI to organize them for you! Here is an example prompt:

“The following notes are from a [recent IEP] for the child I am assessing. Create 2-3 paragraphs from these notes, using parent-friendly language.”

Here’s an example of my notes from a recent IEP review:

  • Qualifies under Autism and Speech and Language Impairment

  • Goals include speech articulation and fluency, being on task, following directions, initiating social interactions, writing and fine and gross motor skills.

  • Accommodations include opportunities for Regina to rehearse what she will say and additional time to formulate her thoughts, breaking up tasks, simplifying instructions, preferential and flexible seating, and making things tangible such as using manipulatives in math.

  • She receives support from the resource specialist for both push-in and , speech therapist, and occupational therapy.

Here is what Bastion created for my report using the sample prompt above:

Regina’s most recent Individualized Education Program (IEP) highlights her strengths and areas of focus to support her learning and development. She qualifies for services under Autism and Speech and Language Impairment.

Her goals include improving speech articulation and fluency, staying on task, following directions, initiating social interactions, and enhancing her writing, fine, and gross motor skills. To help Regina succeed, she will have opportunities to rehearse what she wants to say and extra time to gather her thoughts. Tasks will be broken down and instructions simplified to make them more manageable. She will also benefit from preferential and flexible seating arrangements and hands-on learning tools, especially in math.

Regina will receive support from a resource specialist, speech therapist, and occupational therapist, both in her regular classroom and in specialized settings.

From here, I can edit it for accuracy and to best capture Regina’s history.

Option 3: Speak Your Notes

Platforms like Bastion and NoteZap allow you to create summaries from audio.

This means that you can speak your notes and reflections in real time, and ask it to create a summary of what you’ve shared.

For example, for Regina, I pulled up Bastion’s transcription option:

I pressed “record live audio” and verbally described what I learned from reading her Occupational Therapy report.

Bastion then created a transcript of what I said, and summarized it using the same prompt I shared above. 

Again, from here, it is easy to edit.  I can even run the text through Bastion again and ask it to “rewrite this section more concisely.”

As I’ve mentioned before, one of the most powerful ways we can use AI is to make our work more accessible to families. 

Stay tuned for more tips on using AI to make our reports more efficient and effective for our clients in Part 2: Collateral Interviews.

If you’ve found this helpful, please share with one other colleague who is spending too much time on report writing!

Feel free to reach out using the link below.

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