Pre - Assessment

Possible reliability problems with a written case histroy

- respondent may have misunderstood what was wanted - insufficient time to fill out forms - may not know some info - significant time elapse between onset of problem and the speech language evaluation - events may have hindered ability to recall info - cultural aspects

Medical History

- significant illness - impact on mobility - duration -emotional impact - vision - hearing - medications - any connection to present concerns

Social history

- socioeconomic status - parents' occupations - leisure activities - discipline practices - behavioral concerns - age of child's playmates - feelings and attitudes related to speech and language - interpersonal skills *treating the whole individual not just their speech*

What other professionals can you get info from?

- speech language pathologist - audiologist - ENT - neurologist - psychologist

Closing phase

- summarize major points - indicate next steps in process; going forward with the assessment

What are SOAP notes used for?

- typically in medical settings to report client info between professionals who share a client - used on an ongoing basis and are written immediately after working with client

Developmental history

- typically not taken for adults - birth weight - unusual birth circumstances - feeding difficulties - ages for sitting up, first steps, potty trained - body coordination/motor development - looking for development milestone - educational history

Essentials of nonverbal communication

- walk tall/sit tall - make strong first impression - enter room with a purpose - smile - make eye contact - firm handshake - use your hands - keep hands away from face/hair

Pre assessment info includes:

- written case history - interview with client, spouse and caretakers - info from other professionals

SOAP notes- Assessment

-a synthesis of the previous two sections (subjective and objective) -Includes conclusions and recommendations for the diagnostic

Diagnostic report

1) a written record that summarizes - relevant info obtained - how that info was obtain 2) functions to - guide for further services to the client - communicates findings to client - provides answers to clinical questions

3 types of client interviews

1) information getting - pre assessment 2) information giving 3) counseling

Information getting or intake interview (3 phases)

1) opening 2) body 3) closing

Enhancing credibility in interviewing

1) translate I and You into We and Us and Our - focus on areas of common interest - focus on common goal 2) present self as professional - show concern and interest but not emotional involvement - use words to cultivate cooperation - avoid negative words that might limit cooperation - control the interview

SOAP notes- Objective

Contains measurable findings. For initial diagnostic you would document exam results. For treatment you would include objective performance data -Test scores -Fluency counts -Visipitch readings

SOAP notes- Plan

Record the plan of action. Short term goals for upcoming session included here Will contain the objectives for the next session. It may include a brief description of the materials and activities to be used. This section should be consistent with the original plan of care (semester goals) for the client

What does SOAP stand for?

S- subjective O- objective A- assessment P- plan

What is the SOAP notes- Objective used for?

This information will be useful to the SLP in planning future therapy and in reporting on progress

Writing the report

formats vary with settings but reports include the following areas: - identifying info - background/reason for referral - histories - assessment info -summary/rec -signature of evaluator

Pre assessment info

gathering all the knowledge you can about the client to better prepare yourself

SOAP notes- subjective

non measureable and historical information. includes such things as: - summary of problem from client's or caregiver's point of view -current complaints -relevant past or recent history -client's current level of concern -degree of cooperation -overall affect

Common interview questions

open ended questions not yes/no so they are able to answer the questions in their own way

When is a written case history done?

prior to seeing the client

Feedback loop

saying things out loud and knowing you said something wrong and then changing it

Family history

- age and health of siblings - speech and language backgrounds of parents/caretakers - history of speech/language - family reactions and views/attitudes toward communication disorder being evaluated

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 the nature of the problem changed - client's attitude - attitude of others concerning the problem - impact on communication and socialization - ever treated

Nonverbal pitfalls

- avoid yawning - avoid scratching head - dont bite lip - avoid rubbing back of neck - narrowing eyes communicates disagreement - if you have glasses, don't peer over them - crossing arms across chest - don't avoid eye contact - keep hands away from face - avoid tapping/leg bouncing

Body phase

- go over case history - clarify and confirm

Typical parts of the case history

- identifying info - nature of concern/referral - history of speech or language problem - development history - medical history - school or academic history - social history - family history

Opening phase

- intro -purpose of meeting

Identifying info

- name - birth date - date when history completed - informants name - address - phone -email