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
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Possible areas to include (areas included and not included will vary from one client to the next)
NOTE: Put the following areas tested in priority order, most severe problem first
(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)
Follow guidelines for reporting formal test results; include samples when appropriate
Provide examples of disfluencies, speaking rate, etc.
Describe pitch, loudness, voice quality, and resonance
Describe results of exam in all areas evaluated
Motor: Identify test given and describe client’s performance
Hearing: Describe results of all hearing tests and provide date and location of assessment