Assessment Report Flashcards
What is the purpose of a diagnostic/assessment report?
Report background information regarding the case, results of formal and informal assessments, clinical impressions, treatment recs, goals
What is the purpose of SOAP/Session notes?
Report information regarding the session, progress on therapy goals, impressions and plans for future sessions
One note per treatment session
What is included in an assessment report?
Client information
Background
Histories
Assessment information
Summary
Recommendations
Name/Signature
Why do we write diagnostic/assessment reports?
Inform clients and their families about assessment findings
Organize info into narrative
Interpret assessment scores and describe results
Provide history for client/family
Describe strengths and needs
Interpretation of results
Recommendations
Reason for referral in a diagnostic report includes
Intro to client
Type of eval
Where eval is occurring
Referral source
Concerns of referral/reason for evaluation
What type of background information is needed for pediatric clients only?
Birth
Developmental history
What type of background information is needed for adults only?
Employment history
What is included in background information of a diagnostic report overall?
Facts, who reported them, keep emotion out
Conflicting info is okay but quote the source
What is included in the assessment portion of a diagnostic report?
Behavioral observations
Testing accommodations
All aspects of communication (OME, hearing, etc)
What is included in the assessment results portion of a diagnostics report?
Test name and abbreviation, purpose of the test, age ranges for the test, reference for standard scores
Brief description about what the client was asked to do
Scores in table/graph + interpretive statement about results
What is included in the clinical impressions and recommendations section of a diagnostics report?
Characterize client’s communication/swallowing disorder
Include severity and areas of deficit
Prognosis
State whether SLP services are recommended or not (dosage, targets, strategies to be used, long term and short term goals)
What is an IFSP?
Individualized Family Service Plan
For children in Early intervention Services
Plan developed by parents, service coordinator, professionals who evaluated, professionals who provide services
What is an IEP?
Individualized Education Program
For children in schools
Plan developed by parents, regular and special education teachers, LEA representatives, interpreter of assessment findings, and other professionals, child
IFSP are reviewed every
6 months
IEPS are reviewed
every year but require an eval to be completed every 3 years to determine need for services
What are SOAP notes?
Subjective, Objective, Assessment, Plan
What are SOAP notes used for?
Report client information, communicate with other professionals, communicate with caregivers
1 per session
Various levels of detail depending on clinician and client
Subjective portion of SOAP notes includes
Non-measurable and historical information
Summarize the problem from client/caregiver POV
Client’s cooperation, affect, concern
Objective portion of SOAP notes includes
Measurable findings
Include examination results (diagnostic session)
Objective performance measures on treatment tasks/activities and goals (treatment session)
Session activities, all goals, progress on goal or if goal not targeted
Assessment portion of SOAP notes includes
Synthesis of the information in S&O
Conclusions/recommendations (diagnostic session)
Client’s current status in relation to their goals
What did patient do, what could patient not do, what could patient do with support
Include information about cues/prompts
Plan portion of SOAP notes includes
Next steps and plan of action for client
