1 / 14

Clinical Documents

Clinical Documents. Diagnostic Reports. Purposes. To indicate whether or not a person needs therapy To support that recommendation with all necessary data (IDEA requires that all appropriate tests and measures be used in reaching a diagnosis/recommendation). Identifying Information

kimn
Download Presentation

Clinical Documents

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Clinical Documents Diagnostic Reports

  2. Purposes • To indicate whether or not a person needs therapy • To support that recommendation with all necessary data (IDEA requires that all appropriate tests and measures be used in reaching a diagnosis/recommendation)

  3. Identifying Information Summary Statement Background Information Assessment Recommendations Basic Parts of the Diagnostic Report

  4. Identifying Information • “Vital Statistics” about the client • Include all information needed • Use proper format for order and spacing

  5. Summary Statement • Identify client by name, age, and gender • Identify the purpose of the referral • Identify the speech/language problems and the severity of the communication disorder • Summarize test data to support your recommendation

  6. Background Information • Name, age, and gender of client in first sentence • Referral source and purpose of referral • General History (indicate informant) • Birth and medical history • Developmental milestones (child) • Speech and language description • Home, work, school, social environments

  7. Assessment Possible areas to include (areas included and not included will vary from one client to the next) • Language • Speech • Oral Peripheral • Motor • Hearing

  8. Begin Assessment with General Observations • Client’s behavior and attitude during the evaluation • Reliability of test measures used NOTE: Put the following areas tested in priority order, most severe problem first

  9. Language • Language Comprehension • Language Production (For formal tests, follow guidelines for reporting results: full name of test, test format, client’s results, your interpretation; for informal tests, also include sample utterances/narratives)

  10. Speech • Phonology/Articulation • Phonology • Articulation • Phonetic inventory • Intelligibility Follow guidelines for reporting formal test results; include samples when appropriate

  11. Speech, cont. • Fluency • Voice Provide examples of disfluencies, speaking rate, etc. Describe pitch, loudness, voice quality, and resonance

  12. Oral Peripheral Examination • Tongue mobility • Lip mobility • Palatial mobility • Diadochokinetic syllable rates Describe results of exam in all areas evaluated

  13. Motor and Hearing Motor: Identify test given and describe client’s performance Hearing: Describe results of all hearing tests and provide date and location of assessment

  14. Recommendations • Make a general recommendation for or against therapy. If recommended, indicate type of therapy, frequency and duration of treatment, and location of treatment • Prioritize specific areas to be addressed • Indicate any further testing or referrals needed

More Related