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