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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

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