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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

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Clinical Documents

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  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

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