Quiz 1 Flashcards
What does professionalism entail?
-conduct oneself in manner that maintain as standards expected of that profession
-following ethical standards
-treat all people with respect and dignity
-listening to others
-act responsible and kind even when emotions are high
Professionalism includes
- Physical appearance of the office
- Demeanor of the office staff
- Appearance of the therapist
- Language of the therapist
Scope of professionalism extends to:
- Physical properties
- Nonverbal communication
- Verbal communication
- Written communication
what professional written communication include?
- Diagnostic reports
- Daily treatment plans
- Treatment reports
- Progress notes
- Professional correspondence
- Electronic communication
Diagnostic reports - clinical report
results of
Formal assessment
Includes standardized and nonstandardized tests
Daily treatment plans
Detailed agenda for a session
goals, procedures, cues, behavioral modification
Treatment reports
Summarizes progress, address changes in behavioral
Progress notes
Short synopses written on a session-by-session, weekly or monthly basis
Who is Professional correspondence written to?
To referral sources
Parents
Family members
Electronic communication
Used to relay clinical information
What is the clinical record?
-communication tool to coordinate care
-report that represents the quality of services provided by SLP
-Influence decisions regarding best course of action
-May be required by insurance co for continued treatment
Documentation purposes
- support diagnosis and treatment
- describes client progress
- Justify discharge
- Support reimbursement for services
- Communicate with other professionals
- Justify clinical decisions
- Protect legal interests
- Serve as evidence in court
- Provide data for research
Professional writing expectations
-use professional terminology
-write in appropriate format
-write specific descriptions of client’s performance
To report assessment or treatment results
What are students graded on in clinical practicum?
Paperwork turned in on time
Content
Completeness of report
Paperwork appropriateness for each setting
Professional writing process
1.Standards vary by supervisor
—based on personal preferences and facility requirements
2.Standards vary by setting
3. Professional writing is learned through trial and error
——-students adjust from one experience to the next
——-flexibility and willingness to learn are essential for success
What is the purpose of professional verbal communication?
To make a good first impression
establish oneself as competent and respectable
This is crucial in forming initial relationships with clients.
How do relationships typically begin in a professional context?
Formally
Formal interactions help establish trust and credibility.
What may happen to the style of interaction after rapport is built?
Interactions might become less formal
This shift depends on the clients’ preferences.
What type of interactive style may place some clients at ease after rapport and trust is built?
An informal interactive style
What type of interactive style may reassure clients of a clinician’s competence?
A formal interactive style
Formality can convey professionalism and expertise.
What should skilled clinicians do regarding their communicative methods?
Adapt their professional communicative methods to meet client needs
Flexibility in communication fosters better client relationships.
What should students do in terms of communication style?
Follow the supervisor’s lead
This is important for learning effective communication in a professional setting.
Areas of verbal professional communication
Diagnostic interviews
Patient and caregiver counseling
Staffing (team meetings/rounds)
Professional contacts
Communicating with supervisors
What is diagnostic interview
How interaction with client begins.
Goal is to obtain and gather information
Explain assessment results
Describe patient and caregiver counseling
Talk about diagnosis
Treatment progress, referrals, enlisting help
Can be sensitive area
Be aware of client’s background and level of understanding
Describe staffing
Each professional communicates information in a unique way regarding the client.
Expected guidelines
Describe professional contacts
Will need to give summary of assessment to
Treatment and referral information as well
What are the shared components of professional communication?
Professional terminology
Accuracy of information
Organization
Respect
Objectivity
Sensitivity to context
What considerations to make with professional terminology
Consider context and to whom speaking
When using discipline specific terminology
In written reports, explain discipline-specific terminology
What does accuracy of information entail?
Always refer to data or test results if not sure
Double check when scoring
——read assessment manuals prior to performing evaluation
Consult report for information person is seeking
Provide in timely manner
Use test scores and description of behavior to provide assessment and treatment info
Describe organization
Communication should be orderly in written and verbal modalities
Clinical reports have unique format but ALL highly organized
Verbal stuffings organize as follows:
Background info
Summary of assessment info
Outline of treatment goals
Discuss progress toward meeting goals
Describe respect in communication
Hallmark of communication
Not a courtesy
Demanded by code of ethics
Take into account feelings
Address clients as Mr. Or Mrs.
Listen to the opinions of others
Listen to patient concerns
Respect is also showing in the facility and accomodations
Use surname for supervisors unless they instruct you to use another name
Objectivity in professional communication
Present objective facts in Unbiased manner
During assessment gather info and objectively interpret data
Provide description of behaviors that cause concern
Make referrals as necessary in place of making suppositions
Describe sensitivity to context in communication
- Setting - written report and progress notes are formatted differently based on clinical setting
- Person talking to (audience) - different persons have different levels of familiarity with discipline-specific terms
Adjust format and vocab when needed
Use information given to help you know where additional info is needed
Explain professional terminology in reports
Include parent friendly summary or phone call in addition to report
How students gain professional verbal skills
Observe clinical supervisors and more experienced student clinicians
Model clinical supervisors behaviors
Accept supervisor guidance in planning meetings w/clients and when having verbal interactions
Adjust behavior based on feedback
What is the significance of ethics, confidentiality etc?
SLP is a service profession
Well-being of clients comes first
Confidentiality and safeguarding of info is required
What does HIPAA require
Health care providers to maintain security and privacy of healthcare info
Law from 1996
Health information portability and accountability act
What is considered to be protected health information (PHI)
Protects info and who has access
Name, address, name of employer
Any date, phone & fax number, email
SSN and medical records
What is FERPA?
Family educational rights and privacy act of 1974
What does FERPA state?
Clients and caregivers have the right to read any report containing info about themselves or family
SLPS have to keep accurate data related to client progress
FERPA also protects the privacy of adult students.
SLPS are governed by?
ASHA - American speech-language-hearing association
Different state licensing boards
ASHA expectations
Accurate communications w/ clients and other professionals
Follow professional standards
Accurate representation of SLPs clinical practice
Outline of principle of AHSA’s code of ethics
Principle 1: responsibility to individuals who receive services and research participants
Principle 2: responsibility for one’s professional competence
Principle 3: responsibility to the public
Principle 4: responsibility for professional relationships
Personal privacy preferences
DO NOT HAVE A PLACE IN our professional decision making
What is the fundamental right of all clients seeking clinical services?
The right to privacy
This principle ensures that clients can seek help without their personal information being disclosed.
What type of training is frequently required for students, faculty, and staff in clinical settings?
HIPAA training
HIPAA stands for the Health Insurance Portability and Accountability Act, which sets the standard for protecting sensitive patient information.
What types of paperwork are created in a university clinic?
Drafts and final paperwork related to assessment, treatment, and student training
These documents are crucial for maintaining proper records and student learning.
What challenges do students face when handling paperwork?
New responsibilities, busy schedules, sleep deprivation, feeling overwhelmed
These factors can hinder their ability to manage confidentiality effectively.
What can make it difficult for students to achieve their daily goals?
Being busy, sleep deprivation, feeling overwhelmed
These conditions can impact their performance and attention to confidentiality.
Potential breaches in confidentiality
Daily notes and treatment plans
Formal treatment reports
Formal diagnostic reports
Test forms
Info on flash drives
Electronic transmissions
Authorization forms signed by clients
Therapy schedules
Verbal discussions
Video/audio recordings
What are the necessary parts of the daily routine in a university clinic?
Student clinicians write treatment plans before sessions and progress notes after sessions.
What does a treatment plan detail?
A treatment plan details the clinician’s session plan, including:
* Client goals
* Planned procedures
* Planned cueing
* Planned reinforcement
What is the purpose of progress notes in a university clinic?
Progress notes provide accountability for clinical sessions.
What documentation is included in each progress note?
Each progress note includes:
* Data collection
* Evaluation of client performance
* Plans for future sessions
True or False: Student clinicians write treatment plans after their sessions.
False
Fill in the blank: Student clinicians write _______ after sessions.
progress notes
What does a University Clinic formal treatment report typically include?
Personally identifying information, treatment data, and summary of client performance for an extended period of time
Usually covers one semester.
List examples of personal information included in treatment reports.
- Client name
- Date of birth
- Address
- Contact information
- Referring physician
- Diagnoses
How is confidential information managed in a University Clinic?
It is created, read, and reviewed outside the view of others.
True or False: Many universities provide computer labs for graduate students to create and edit confidential information.
True
What is another name for a diagnostic report?
Assessment or evaluation report
What kind of report contains more personal info than any other clinical report? university
Diagnostic
What clinical report contains historical information related to client and family universitiy
Diagnostic report
What info is included in diagnostic/assessment/evaluation report? university
Test results from SLP (standardized, etc.)
Test results from informal SLP testing (language sample)
Interpretation of results
Diagnosis
Prognosis
Recommendations - including referrals
Info on flash drives - university
-some universities allow
-info cannot identify client
-in small towns if rare disorder could still identify
- requires special care
Some universities don’t allow
—-have designated labs
—-secured w/in facility
—students cannot plug into their device
Electronic transmission - university
Encrypt files
Can reference by client appointment date and time
If outside organization as to call
Authorization form -university
Scan as soon as possible to avoid anyone other than clinical staff from viewing it
Therapy schedules - university
Appointments and cancellations are confidential
Aware of arrivals b/c work in the clinic-reserve room, prepare and clean up
Students will observe others being treated, confidentiality must be maintained
Wait until in room to discuss confidential info with client
Verbal discussions - university
Be mindful what discuss with other students as others may overhear
Academic classroom are appropriate places to ask about specific procedures and goals
-ask without disclosing confidential information
IF YOU HAVE ANY DOUBT ABOUT WHETHER TO DISCUSS INFORMATION ABOUT A CLIENT, THEN DON’T
audio and video recordings - university
Various devices are used for data collection, analysis of session w/ supervisor, self-analysis and client feedback
Protect privacy by:
-listen or watch in private location with few interruptions
-delete recording immediately after using for purpose
Medical setting
Chart differed in that many different professionals have access to and document in the chart
Charts are stored in a central location
Hospitals, rehab centers, long-term care facilities, nursing homes, skilled nursing facilities
HIPAA - medical setting
Know medical facility policies related to patient confidentiality and sharing client info
Discuss patients ONLY with others involved in patients care
If non communicative cannot advocate for self
- may still be aware of what others are saying
Should communicate with each patient as if fully aware - provides dignity
What must you always be conscious of when regulated by HIPAA in medical setting?
Who, what, where, and when: know WHO you can talk to, WHAT you can talk about, WHERE you can talk about it, and WHEN it is appropriate to talk about it
Paperwork in a school setting
Drastically different from University clinic, private practice clinic and medical setting
Impacted by federal regulations that govern schoo and
Service delivery method provided in schools
IDEA in school setting
Reauthorized school services in 1990 renamed to IDEA
3-21 diagnosed with communicative disorder entitled to
Free and appropriate individualized services
Child must qualify based on extensive evaluation
IEP is written if qualified, unique to school setting
IEP qualification standards differ from university and private practice clinical standards
IEP copies
Originals keep in student’s file in admin office
Parents receive copies at meetings or upon request
Can be sent to other professionals at paren’ts request
Graduate practicum clinicians implement goals under supervision of school SLP
Teachers and other professionals involved get IEP copy
What is listed in IEP
Classroom accommodations and modifications
Goals
confidentiality and ethics - IEP
Failure to implement stated goals is a violation of federal law
Each person working with child is accountable
Graduate clinicians should learn safeguarding policies used at the school and follow
Clinical folders for students include - school setting
IEP
Test results
Treatment plans
Progress notes
Copies of diagnostic report
Therapeutic materials
Correspondence
Work samples
List of students likes and dislikes
Parent contact info
Recordings
Recording permissions - school
Most require parental consent
At graduate clinic ONLY record if received permission from school SLP first
