Pre-Assessment
Typical Parts of Case History
-identifying info -nature of concern/referral -history of speech/language problem -medical history -social/family history
Assessment
Assessment is a synthesis of 2 previous sections -includes conclusions/recommendations 4 diagnostic -for treatment point out status in relation to clients goals -contain narrative summary of information in subjective and objective sections
Writing the Report
Identifying information Background/Reason for Referral Histories Assessment Info Summary/recommendations Signature of Evaluator
Opening Phase
Introduce by pointing out purpose of meeting Give overview of what assessments were done
School or Academic History
age started school failed or skipped grades academic strengths and weaknesses development of friends concerns
History of Speech or Language Problem
age when problem started under what circumstances has nature of problem changed clients attitude impact socialization/communication
Family History
age/health of siblings speech/lang backgrounds of parents and caretakers history of speech/lang disorders of other fam members family reactions and views toward comm disorder being evaled
Nonverbal Pitfalls
avoid yawning avoid scratching head (confusion) don't bite lip (anxiety) don't peer over glasses keep hands away from eyes/ears/nose
Common Question Interviews
describe the problem how did the problem begin gradually/suddenly? how do you react
Translate i/you into we/us/our
focus on areas of common interest -> child focus on common goals -> helping child, discovering problem, making a difference
Body
go over case history clarify and confirm
Function of Diagnostic Report
guide for further services to the client communicates findings to client communicates to other professionals provides answers to clinical questions
3 Types of interviews
information getting - pre assessment information giving counseling
Written Case History
insufficient time to fill out forms may not know some information cultural aspects
Opening
introductions purpose of meeting
Info from other professionals
many time see other professionals -ENT -audiologist -neurologist -psychologist NEED PERMISSION (CONFIDENTIALITY)
Objective
measurable findings-info will help SLP write future therapy plans test scores fluency counts visipitch readings
Identifying Information
name birth date date when history completed informants name address phone email
Subjective
non measurable and historical info: summary of prob from clients POV current complaints relevant past/recent history clients current level concern degree cooperation overall effect
3 Phases of Interviews
opening body closing
Plan
record plan of actions/short term fails for upcoming sessions contain objectives for next session -brief description of material and activities used -should be consistent w original plan of care (semester goals)
Present self as a professional
show concern and interest but not emotional use words; collaborate, control, team, solve, work avoid negative words that close communication control the interview
Medical History
significant illnesses impact on mobility duration vision emotional impact hearing meds
Social History
socioeconomic status parents occupations leisure activities discipline practices behavioral concerns age of child's playmates feeling and attitudes related to speech/lang
Closing
summarize major points indicate next steps in process
SOAP Notes
typ in medical settings to report client info b/w professionals who share client uses on an ongoing basis and are written immediately after working w client
Development History
typ not taken for adults birth weight unusual birth circumstances feeding difficulties ages for sitting up/first steps/potty trained body coordination/motor development
Essential Nonverbal Communication
walk/sit tall make strong 1st impression enter room w/ purpose smile make eye contact firm handshake
Why is the summary important?
will be presented so other professionals other than SLPS can understand the outcomes from the session
Pre-assessment info include:
written case history interview w client/spouse/caretakers info from other professionals more you know prior the better prepared
Diagnostic Report
written record that summarizes -relevant info obtained -how that info was obtained
Body of Interview
Discuss major findings Language should be free of jargon -explain terms the child may not know Use illustrations, photos, examples to help client
S.O.A.P
Subjective Objective Assessment Plan