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Stack #4637864
| Question | Answer |
|---|---|
| What does the exit conference include? | What was done today (or measured)? What were the findings in relations to the norms or standards? What is the outlook for improvement? What is recommended to be done? (test administered) |
| Questions that we need to ask | Do I have enough information to answer the diagnostic question with confidence? Have new areas been identified during the evaluation? How do you organize the information so the patient and the family will understand the problem? |
| Questions that we need to ask | How do we present the information, so the client regards the information as satisfactory? (repeat key ideas, sandwich information with pos and neg info,) What other diagnostic procedures or examinations might be useful to them? |
| Questions that we need to ask | Do I know enough about the problem to recommend therapy or not? (learn through ASHA, refer to others) Have I given them sufficient opportunity to ask questions, express their feelings, and to sort out any decisions about what to do next? |
| Clinicians as Counselors | The counseling function begins in the diagnostic setting and extends throughout therapy |
| As Counselors we need to do three things | Help - help the client/family discuss areas of concern Provide - provide motivation Offer - Offer support |
| Educating the Client Will | Enable patients to understand the results Understand the general features of the disorder Understand the implications for management |
| Making Recommendations | General recommendations Recommendations that change someone’s behavior Recommendation to stop a behavior No therapy is recommended Recommendation to another discipline |
| The final step is to secure confirmation of the patient’s intent to carry out recommendations | Immediate Action Delayed Action |
| Diagnostic Report | a written record that summarizes relevant information, a clinician obtained, and how they obtained it. |
| Purpose of the report | It acts a guide for further services to the client Official record of the meeting w/the patient Communicates clinician’s findings for other professionals Serves as a doc for research purposes principal way in which we relay info to other professionals |
| Organizing the diagnostic Report | S.O.A.P I.E.P |
| S.O.A.P | S=Subjective (interview and case history information) O=Objective (test results) A=Assessment (summary and impressions) P=Plan (recommendations) |
| I.E.P | a student focused plan devised by a team of teachers, school administrators, special educators, and parents |
| IEP should be able to answer these questions | 1. What is the problem(s)? 2. Where is the student now? 3. Who will do what with the student and how often? 4. When and how will progress be measured? |
| Diagnostic Report | Regardless of the format, a diagnostic report should be organized for easy retrieval of information and be prepared in a manner that reflects high professional standards |
| Criteria that should be used to judge a diagnostic report | Is it accurate? Is it complete? Is it efficiently written? Was it prepared promptly? |
| General format for a diagnostic report | Routine Information Statement of the Problem/Reason for Referral Historical Information/Case History Evaluation Clinical Impressions/Summary Recommendations |
| Routine Information | In this section we present basic identifying information… Client’s name Date of Birth/Age School/Grade (if school age) Date of the evaluation Clinician’s name Referral Source (parent, teacher, physician…) |
| Statement of the problem/reason for referral | We want to make a statement about the presenting problem (1-2 sentences) What is the complaint and who is making it? Example: Mrs. Smith was concerned about Joey’s speech intelligibility. |
| Historical information/case history | Include information from: -Referral letters -Case History -Interview |
| Include information about the client’s | -development -medical history -educational history -family history |
| Evaluations | Provide the name of each test and the area(s) that they assessed Include the test results The information is presented, not interpreted Example: Joey’s standard score of the vocabulary subtest was 112 which placed him in the 75th percentile. |
| Clinical Impressions/Summary | Summarize our impressions of the individual and the communication impairment |
| Want to answer the following questions… | 1. What type of speech or language problem does the client have? 2. How severe is it? 3. What caused it? 4. How does it interfere with everyday functioning? 5. What are the prospects for treatment? |
| Recommendations | Recommendations should be specific and brief Do not recommend specific evaluations or remediation procedures to workers in other professions Include a statement about whether the patient/family plan to follow through with the recommendation |
| We should be able to answer the following questions | 1. Is therapy recommended? 2. Do we recommend further speech and language evaluations? 3. What happens now and where do we go from here? |
| Confidentiality | For you to release any information, you need to get the client’s permission in writing The original copy of the report are kept in the client’s clinical file. |
| Professional Writing Style | Use simple language Use complete sentences Keep “I” out of the report, refer to yourself as “the clinician” or “the examiner” Make sure spelling, grammar, and punctuation are accurate |
| Professional Writing Style | Avoid contractions and hyphens Avoid abbreviations Make the report “tight.” Do not leave gaps Review and rewrite as necessary Define technical language Use statements that can be supported by fact |
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