Clinical documents
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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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Clinical Documents

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Clinical documents

Clinical Documents

Diagnostic Reports


Purposes

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)


Basic parts of the diagnostic report

Identifying Information

Summary Statement

Background Information

Assessment

Recommendations

Basic Parts of the Diagnostic Report


Identifying information

Identifying Information

  • “Vital Statistics” about the client

  • Include all information needed

  • Use proper format for order and spacing


Summary statement

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


Background information

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


Assessment

Assessment

Possible areas to include (areas included and not included will vary from one client to the next)

  • Language

  • Speech

  • Oral Peripheral

  • Motor

  • Hearing


Begin assessment with general observations

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


Language

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)


Speech

Speech

  • Phonology/Articulation

    • Phonology

    • Articulation

    • Phonetic inventory

    • Intelligibility

      Follow guidelines for reporting formal test results; include samples when appropriate


Speech cont

Speech, cont.

  • Fluency

  • Voice

    Provide examples of disfluencies, speaking rate, etc.

    Describe pitch, loudness, voice quality, and resonance


Oral peripheral examination

Oral Peripheral Examination

  • Tongue mobility

  • Lip mobility

  • Palatial mobility

  • Diadochokinetic syllable rates

    Describe results of exam in all areas evaluated


Motor and hearing

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


Recommendations

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


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