5 - Professional Communication & documentation

Question 1

Types of professional documentation: (4)

Answer 1

Assessment session plan / intervention session plan

Progress / Case Notes

Assessment Summary Report

Therapy summary reports

Question 2

4 Types of professional documentation

Assessment session plan / intervention session plan

When:
Aim & purpose: (3)
For who: (3)

Answer 2

When:
Before every session

Aim & purpose:
Plan & procedure for your assessment
Outline goals rationales, priorities & procedures for assessment / intervention
Planning & clinical learning

For who:
For your learning
For your PPE
Peer to review

Question 3

4 Types of professional documentation

Progress/ case notes

When: (2)
Aim & purpose: (5)
For who: (3)

Answer 3

When:
After every assessment / intervention
After phone calls, meetings

Aim & purpose:
- Provide summary of assessment/ intervention session
- Strategies, client progress against goals
- Plan for next session
- Document any follow-up
- Medico-legal requirements

For who:
- Client
- Other team members
- Potential medico-legal matters

Question 4

4 Types of professional documentation

Assessment Summary Report

When: (1)
Aim & purpose: (2)
For who: (3)

Answer 4

When:
After assessment is completed

Aim & purpose:
Provide summary of assessment results
Recommendations and identify if any further therapy is required

For who:
Client & family
Other professionals
Other slps

Question 5

4 Types of professional documentation

Therapy summary reports

When: (1)
Aim & purpose: (2)
For who: (3)

Answer 5

When:
After assessment is completed

Aim & purpose:
- Provide summary of intervention block & clients progress against the goals
- Recommendations & identify if any further therapy is required

For who:
Client & family
Other professionals
Other slps

Question 6

Aim of clinical report:

Answer 6

Document & share information relating to SP service provided

Question 7

Professional documentation:

When?

Answer 7

Written at various stages

Question 8

Professional documentation:

Shared with?

Answer 8

Variety of stakeholders
Eg: client, significant others, GP, school

Question 9

How does professional documentation relate to Professional Standards?

Answer 9

Domain 1: Professional conduct

Question 10

How does professional documentation relate to Code of Ethics?

Answer 10

Code of ethics:
2.2 Accurate & Timely Information

Question 11

Documentation

Confidentiality: (2)

Answer 11

we keep information about clients private

To safeguard clients’ confidentiality, share information only with those authorised to access it.”

Question 12

How long to keep children’s records?

Answer 12

7 years
Or until children turn 25 yrs old

Question 13

Adapted consent forms:

Answer 13

Adapted consent forms;
Use pictures, symbols & simplified text
Ensures people who are ill or have significant communication difficulties can provide informed consent

Question 14

Clinical Reports

Considerations (4)

Answer 14

Context
Readers
Writers
Documents

Question 15

Clinical Reports

Minimal requirements: (8)

Answer 15

Dates and author details

Referral information

Background information and sources (MHx and SHx)

Assessment results

Functional impact/interpretation of results

Therapy goals and progress (if relevant)

Impressions/diagnosis

Recommendations- including functional strategies

Question 16

Incorporating ICF in reports allows for: (2)

Answer 16

Person centred
Strengths based approach

Question 17

Providing Feedback - counselling

Summarising Results (3)

Answer 17

Make a time to talk through the report in person
Provide feedback during the session
Consider how you will provide Verbal handover

Question 18

Support your client (4)

Answer 18

• The “helping relationship”
  Respond
• Recognise and refer
• Empathy
• Mental Health & trauma
  How much info do I provide & when?

Question 19

SPA Professional Standards: Counselling

Answer 19

We provide counselling within the scope of the SP role in relation to communication & swallowing
Refer to other professionals as required

Question 20

Stein-Reubin Post Evaluation Toolkit (Funnel): (8)

Answer 20

Flow talk

Highlight positive attributes and general strengths

Clarify your role

Highlight communication strengths

Enlist the family in the diagnosis

Written recommendations

Question and answer period

One important take-away

Question 21

Accessible Information:
Guidelines: (5 steps)

Answer 21

5 steps
Step 1: A short message
Step 2: Clear sentences
Step 3: Easy words
Step 4: Good layout
Step 5: Make a set with same layout

Question 22

Aphasia Friendly Information

Considerations (3)

Answer 22

Barriers and facilitators relating to content and design

Need to consider dialogue

Individual needs and preferences

Question 23

The assessment Process (5 steps)

Answer 23

Step 1:
Familiarise yourself with the procedure, appropriateness to client

Step 2:
Complete test items with client

Step 3:
Calculate raw scores
Consult norms for client’s age
Determine scaled scores

Step 4:
Scaled scores -> determine if client is within normal limits, performing above or below expected for their age

Step 5:
Once you have these numbers in mind
Feed this back to the family, agency/doctor

Question 24

Key components of a report (6)

Answer 24

1: Demographic information for the client

2: Appropriate headings (e.g., medical history, reason for referral, findings)
Background information: developmental milestones, medical history, past access of services?
Assessment findings: organised around practice areas (voice, speech fluency)

3: Objectivity and accuracy in reporting

4: Prioritisation/focus on major points or findings

5: Summary – the “so what”

6: Recommendations

Question 25

Ethical considerations

Answer 25

All info generated from AI requires critique from SP to ensure currency, accuracy and relevance and to support its communication in an accessible form to service users

Question 26

Can you put private information into ai?

Answer 26

No, avoid putting identification of clients, you don’t know where it will be going