2nd powerpoint
Discharge Report
-Record of the client's status at the conclusion of treatment -Reason for discharge -Recommendations for future: what does your real world include -at termination of treatment, one final report about what happened, why discharged, recommendations in real world -initiation: initial evaluation report -termination: discharge report
Affect Response/ Reflecting Feelings
-Empathetic listening- Listening to what they say and don't say. (This helps the person open up.) -Assign an emotion to the content -Not "parroting" but confirming how they feel. -feelings involved, describe feeling associated with it -paraphrasing but adding feeling to client to give them that word to work
Progress Note
-"S.O.A.P" Notes -Most commonly used method of writing about progress : S= Subjective information O= Objective information A= Assessment P= Plan
Clinical Findings / Test Results
-"Test Results and Observations" -Includes formal and informal measures -Assessment of basic categories _?__ & Functional communication Oral peripheral Hearing screening Related information
Prompts and Cues
-"prompts" and "cues" are often used synonymously but........ -Prompt- strategies or reminders to support a target -Cue- more specific and direct and shift the client's attention -initial nudge: prompt (this is what you are going to do) -cue: more specific -how to get a client's output -in general, synonymous in clinical practice
Our DU SLH Clinic Summary of Progress Report
-A periodic summary of progress -Re-evaluation of client's goals -Communicate information to client -look at baseline data and progress data -summarize in print and verbally
Summary and Recommendations
-A succinct synopsis of the findings -Severity ratings -Other relevant factors
Prognosis
-An assessment of the patient's potential for improvement -Often include factors that contribute to sustaining the gains
Purpose of the Initial/Diagnostic Evaluation Report
-Answer patients questions -Establish a diagnosis -Describe current communication skills -Make recommendations for therapy
Guidelines
-Avoid conversational writing style -Write in the third person -Don't use contractions -Report test scores and interpret them -Disabilities versus abilities -Be objective -Only express opinions if identified as such
Content response
-Best to stay on task with what you know best for beginning clinicians and new relationships -Most common response -Offer facts about assessment results and communication disorder -Establishes credibility for the professional -talk about their communication issue, start with what you know, what techniques I know -when you establish you know something: builds rapport right off the bat, makes person trust you
Recommendations
-Brief statement of a plan of action to remediate the problem -May include suggestions of specific techniques tried during the evaluation - stimulability
Background Information
-Chief complaint -History of the problem -Any information directly relevant to the current communication problem
Lesson/ Treatment Plans
-Composed of a series of behavioral objectives -Vary in level of difficulty -Provides basis for data -in our clinic, medical setting: treatment plan -lesson plan in schools -Mrs. Marra's: Lesson Plan -start with something child will achieve success with, end with same, more challenging in middle
Client Demographics
-Contact information -Date of birth -Date of evaluation -Diagnosis -Diagnostic code (ICD-10 International Classification of Diseases) -Primary Care Physician
Goal Development
-Demand for Evidence-Based Practice (EBP)- "treatment efficacy and fiscal accountability" (Guilford, Graham, et Scheuerle, 2007) -Goals must be specific, measurable, and functional. -not making this stuff up -make them specific, measureable (criterion), functional
Initial Evaluation Report
-Demographic information -Background history -Clinical status/ Summary of testing -Prognosis -Summary and recommendations
Plan of Care/Treatment
-Demographic information: ICD 10 Codes -Background history, and summary of clinical status -Long term goals and short term objectives -Frequency of treatment -Discharge criteria -demographic: name, address, serial number, significant other -ICD 10 Codes: diagnostic codes that tell you what diagnosis is, supporting behavioral objectives, procedural code (CPTs), claims for services, -background history: chief complaint, medical history, etc -long term goals: broad outcome, short term objectives: behavioral objectives -frequency: dosage of treatment, how often they will be seen and how long will they be seen -Discharge criteria: reassess if you met all objectives
The Criterion Statement
-Describes how well the behavior needs to be performed -Percentages -# of times -Clinician cues -relevant to task -12 out of how many? -think if the number means anything to you and reader -does it support if the client is doing better?
The client will produce a sentence with "N+V+ing" with 75% accuracy given a model.
-Do: produce a sentence with NVing -Condition: given a model -criterion: 75% accuracy
Task Order
-Easy Hard Easy -"The work zone success rate" < 50%- Too hard 50% to 75%- Target Work Zone 90% or above - Mastery -think about work zone when situating objectives with session
We know the disorder details, what about the
-Emotional effects of Communication Disorders -redundancy: twice stresses its important, lets someone process it more, saying something in 2 sections as people skip around -counseling: part of what we do as SLP -all about listening, understanding, etc. -sometimes not a happy story: unhappy communication story -frustration, why? -examples of providing feedback and generalizing therapy vs. counseling -maintain professionalism, but allow them to talk about problem -move through emotional effects while maintaining goals
3 main phases of counseling in SLP
-Establishing the therapeutic relationship: Information Gathering Interview -Implementing intervention: Information Giving Interview -Terminating the therapeutic relationship -not in our scope of practice to deal with mental illness -as things come up, as long as they are about communication and its effects, then it is apart of our scope of practice -if they will harm themselves, refer to right people -whenever we do diagnostic evaluations, we have to ask to get information from client (Information Gathering Interview) -Information Giving interview: tell diagnostic, make plan with client, talk to them about prognosis, counseling element after sharing information -3rd is termination event: we did what we could do for you, counseling elements too
Assessment con't
-Example: "The client produced /l/ with greater accuracy this session. She responded well to the verbal cue "lifty sound". Using placement cues, e.g. the tongue touched your teeth" was effective. -provide information from previous session to show progress -need to know how they did last session
Progress Notes
-Following your session- report on the client's performance (Remember your data collection?) -This document ties in all of the information from your lesson plan -Use the lesson plan as an outline -day before session: give treatment plan to CI -write TP, write progress note right after session -absolutely need to write a note: so you know what to do next time, if someone else steps in, don't get clients confused, medical records is part of our profession (state and federal mandated guideline) -progress notes: money was paid for treatment, "receipt," business practices -in all settings: schools and medical session -data collection comes into play: report on your data in progress note (make it past tense)
The Condition Statement
-Given a model -Given printed text -Given pictures -More....? -environmental condition -given printed text -picture stimuli -given communication partner
Options....
-Goal: To improve liquids to an age appropriate level. -Objective: The client will_____ with _____% accuracy given________. -only record data in regards to behavioral objective, but make side notes -Articulation disorder -The client will produce the /l/ phoneme in the initial position at the word level with 75% accuracy given a direct clinician model. -start with goal and put all objectives underneath, then next goal
Reframing
-Help the client or family to look at the positive side. -Not to be used early on in the relationship. -finding silver lining -more positive side -but don't dismiss what they feel
The Activities
-How will you have the client achieve the established objectives? -Materials Used? -Use of continuous or intermittent reinforcement? -how will you use this in therapy? -making sure activities don't distract from actual behavioral objective
impairment vs disability vs handicap
-ICD: International Statistical Classification of Diseases and Related Health Problems (ICD) -continuum -communication disorder does not need to be a handicap, but could be -like stuttering: very severe, can't interact with people in environmental, limit abilities in real world and change quality of life, if its debilitating to them and changes who they are and what they do
Subjective Information
-Information about the client's demeanor -The client's attendance -Example: "The client appeared fatigued." -"The client arrived with his mother and appeared eager to begin." -don't use very and really for subjective part -subjective is only about client
Silence
-It's OK to say nothing! -Embarrassed silence- don't fill the silence immediately, and the client will! -Use minimal encouragers -hard to be silent and listen to the other person -truly truly listen -take in verbal and nonverbal for empathy -harder to do when the other person isn't talking as much -let the other person communicate -we use minimal encouragers: when making sounds like "oohhh" "mmm" smile, "yeah, "I know", "tell me more" -passive listening -active listening is words
Collecting Data to Modify LP
-Look at SK 9/27/07 for data collection... -Make a score sheet with three columns (correct, incorrect, with a cue) -Keep data from first event. How did she do? After cueing, how did she do? -Let's modify the lesson plan- a new Behavioral Objective?
A "Good Report" :
-Meets the need of its audience -Written clearly and succinctly -Documents all important findings from the evaluation -Written in a professional tone -who is reading this report: parent, SLP, teacher, client, physician, insurance -this report can be lengthy, have to think about including words that need to be stated and words directly related to recommendations, concise -support what you said you were going to be doing, document and justify the need or not need of treatment -make clinical decisions -has to sound smart
Sharing Self
-Offer personal information as able and appropriate. -It's ok to appear human. -talking about your side, tread lightly because we don't have a communication disorder -don't want to diminish what they feel! -as relationship progresses, share a little bit of yourself -not about you, but makes them feel like they aren't alone -make yourself more genuine to client
Components of the Evaluation
-Patient demographics -Background history -Clinical findings -Summary -Prognosis -Recommendations
Counterquestion
-People rarely want advice. -Asking the same question assists them with finding the answer. -Very productive response. -Good for the initial stages of a relationship. -ask them same question back -better if them come up with answer than if you do -locus of control: responsibility of information on client
Identification
-Professional name -Highest degree earned -Certification status -Title -signature Caterina Staltari, M.A., CCC-SLP Clinical Assistant Professor Director of Clinical Education
Empathy
-Remember to put yourself in the client's "shoes"- different from sympathy -What stage of the "grief" process is the client and the family? -What level of awareness are they? -hard for us to understand what it is like to have a communication challenge: how do we find empathy -i can only imagine what it must be like for you -don't have sympathy: pity, I am sorry for you, in that moment with you, sad together -empathy: more mutual understanding, I want to understand and share what you are going through but I can't be sad too -can't break down with the client, need to be strong in their situation -empathy is important in establishing, implementing, and terminating -where is this person in the understanding we are talking about, how much do they understand communication disorder, how far in awareness about communication disorder
Paraphrasing Content
-Repeat what the client has said. -May or may not attribute feelings at this stage. -Allows the client to "re-hear" what they said, and add further information. -repeat what they said -they are the ones saying the words -guide client to make the decision, think that they came up with it -...yeah and -during interviews, specifically information gathering interview, want them to tell you as much as possible -tend to elaborate more
when making a behavioral objective
-Rewrite it accurately: do not keep 100% -make it measurable, specific, functional
Most Common Errors
-Sentences too long -Relying on spell check -Too much information -Redundant information -Extraneous information -Poor sequence/ flow of ideas -Inaccurate interpretation of results -Poor / inconsistent prognosis
Proof reading Clinical Reports
-Spelling, grammar, punctuation correct? -Professional terms/ tone used? -Redundancy of word usage? -Rambling or lengthy sentences? -All important client information added? -Appropriate information in the appropriate section of the report? -Follows a logical sequence? - data is interpreted, not just reported? -Are conclusions and assumptions supported by data?
Objective Information
-Statement of data -Data should relate to objectives -Relevant findings can be included to support the data -"The client produced /l/ with 80% accuracy following a model. Topple was used as reinforcement" -in past tense -findings support data -quantitative data
Professional Tone
-The goal is to have the reader have faith in the writers information. -Needs to sound "smart" -Refers to the attitude your writing conveys to your audience. -has own attitude and sounds professional -not flowery or very explicit, right amount of information
Goals in Group treatment
-The number of utterances in a 90 minute session -Word retrieval skills following a Wh? -Sentence structure (e.g. use of N+V) -How would you write a Goal? An Objective? -goal: to improve expressive language to a functional level -behavioral objective: the client will retrieve content words with 75% accuracy following a Wh question -everything based off of evidence-based practice to create behavioral objectives
More Practice
-Using stimuli, develop possible behavioral objectives... -The GOAL: Language, Articulation, Fluency ? -The OBJECTIVE:
Plan
-What are you recommending? -Next session what do you want to focus on? -"plan to move /l/ to the sentence level next session" -P: plan for next session -everything ties together -indicate you plan to move to sentence level
The Goal
-What is the broad outcome that you want to achieve? -What is a goal for... ..... Improved fluency .....Improved language .....Improved articulation -broad goal: improve fluency to a functional level, etc. -I need to fix this person's what? -includes do, action, criterion statements
Level of cueing
-What type of support will you give? Models, pictures..... -What amount of support will you give? -Minimum: 25% or less of time I had to supply support to client -Moderate: 50% of time -Maximum: 75% or more of time -not talking about cue itself, but amount or quantity of cue -verbal cue, direct model, etc.
Modify the lesson plan summary
-Write the goal -Write a new objective -Be sure to include: The criterion The action The level of clinician support
Assessment
-Your general findings -Overall, how did the session go? -Relate your comments to the client's objectives -Include your cues that were effective -Reflect on the session -Compare data from previous session -your interpretation of what happened, relative to data in objective -how session actually went -talk about clinician cues more effective, repetitions, progress improved throughout trials -clarify information -don't use subjective information -show improvement from previous progress note -qualifying data
Other Examples of activities
-book is simple -blocks -simplest can be most productive -stimuli inherent in task -pair stimuli with task keeps task productive
Breaking the silence.... Use counseling techniques
-content response -counterquestion -paraphrasing content -Affect Response/ Reflecting Feelings -reframing -sharing self -bag of tricks: how to redirect client to task within session
Clinical Reporting
-initial evaluation report -plan of care -daily progress notes -summary of progress report -discharge report -required to do this in the fall -initial evaluation report: family telling stuff, where is this person currently after diagnostic tests, get a sense of where they are, summary and recommendations, needed for records, professional to identify whether there is a problem or not, substantiate recommendations, doesn't always lead to therapy -plan of care: if need therapy, our legal document to talk about issue and things we are going to do to remediate their issues, behavioral objectives go into plan of care, show time frame for person -daily progress note for every time you see them -summary of progress report: for a long period of time, how to talk about data across sessions, specific to Duquesne -discharge report: when termination of therapy
how do we know how to find treatment approach?
-looking for evidence of treatment -what are best practices for disorder
Components of the lesson plan
-outline of treatment session -clinician aren't referring to them too too much -treatment plans don't change drastically from session to session -outline for Progress Note -goal: broad outcome -objective: what you are measuring -activity: what you are going to be doing -materials: what is in the room -comments: comment to clinicians themselves (could also tally here)
Use the Lesson plan for the SOAP Progress Note Format
-take it how it is written in treatment plan -start off with goal: move to activity then talk about objective -one goal with multiple objectives -to improve liquids to an age appropriate level, the client engaged in structured speech production tasks at the word level. The client produced in the initial position of words... -then list activities with objectives that fit under that goal, no matter the goal -lesson plan helps with O section of progress note
Representational Hierarchy
-text is harder (more abstract), object is easier -isolation is easier, connected speech harder -objects are easier for child than paragraph about object
Prompts and cues use varied sensory modalities
-visual, auditory, kinesthetic, tactile -we have whole tool kit of clues -included in behavioral objectives
The Evidenced Based Process
1. Pose a clinical question 2. Search for best evidence 3. Evaluate evidence 4. Consult with client and make a clinical decision 5. Implement clinical decisions -only way to provide services -pose a clinical question: assess, what disorder do they have -search for best evidence -evaluate it and determine what approach to do -consult with client or caregiver -implement clinical decision
Evidence Based Practice
ASHA's Position : "The term evidence-based practice refers to an approach in which current, high-quality research evidence is integrated with practitioner expertise and client preferences and values into the process of making clinical decisions." Treatment: 1. Research 2. Client Goals 3. Clinician expertise -you know the literature more -take your clinical expertise, and research, and explain to client -when we provide services for people -they understand what they are supposed to do -this is what we should do for you, questions, etc. -co-create scenarios for them
Three General Guidelines: Always Consider:
Audience- other clinicians, client, health care professional, insurance provider, teacher, Purpose- justification, education, status Begin with the "end" in mind- e.g. if recommending treatment- your report should show deficits Time considerations- length of report/ length of treatment
Modify objectives to modify the Lesson Plan
Change the percentage (criterion) ... with 75% accuracy ... to ... with 80% accuracy. Change the stimuli (conditions or action) ... given direct modeling...to... given initial prompts -change the percentage -change the stimuli because they were too easy -action, condition, or criterion -50 to 75% to start, keep it away from 100 by changing things -plan of care: what you are projecting to do
Goals and Objectives
Goals: The broad Outcome for treatment Objective: The measurable outcomes for each session.
From lesson plan to progress note
Lesson Plan Goal: To improve production of liquids to an age appropriate level. Objective: The client will produce the /l/ in the initial position of CVC shape words with 80% following a clinician model. Progress Note To improve production of liquids, the client produced /l/ in the initial position of words following a model with 70% accuracy following a clinician model. She increased to 80% accuracy with additional verbal cueing.
Materials and Comments
Materials -What will you bring in? Comments -Your data record -Reminders for treatment tasks -Time frame for activities -don't need materials and comments across time
Modifying Lesson Plans
Modify tasks -Based on performance -Based on functional needs -Based on a representational hierarchy(from least to most abstract) Modify behavioral objectives -if client does well: modify treatment plan -modify tasks: goal probably won't change, will change task or activity, will change situation -can also do this with representational hierarchy: make it more difficult (/s/ from isolation to discourse level)
The SOAP note
S- Opinion regarding relevant client behavior/status in brief statement O- Record data collected for each task A- Interpret data and compare to prior data P- Identify proposed targets for next session
The Behavioral Objective...
Three components of the Behavioral Objective: 1. The Do: action 2. The Criterion: accuracy, how many times 3. The Condition: cueing, stimuli, environment
The Behavioral Objective
What specifically will the client achieve? Remember the three components: 1. The Do Statement (The Action) 2. The Condition 3. The Criterion
all reporting must
include relevant findings about: -progress -treatment approach: services provided -need to know what you about to embark on -all reports include names in actual records -emailing: deidentified
CW a 11 year 5 month old male came to Duquesne University Speech- Language - Hearing clinic on September 8, 2012. Before that, they saw him at Children's Hospital on Jan 5, 2012. At that time he was diagnosed as a stutterer. C received 10 sessions at the facility from January to August, 2012. He was then placed "on hold" due to scheduling conflicts. Mr. W. Said the client also received speech therapy in the school once per week.
make more professional and confident -an, presented to the -Prior to that, he was treated -with a stuttering disorder -The client's father informed that