Reporting Assessment Findings Flashcards
1
Q
Opening Phase
A
purpose
time
adequate info obtained
client behavior
2
Q
Body of Interview
A
major findings
language easy to understand
emphasize major points
3
Q
Closing Phase
A
summarize major findings, conclusions, recommendations
Comments/questions?
Thank for help
Next steps
4
Q
Guidelines
A
Does it contain all major info needed? Is the info categorized appropriately? Is there redundancy? Is it too wordy? Sentences too long? Terminology used correctly? Written objectively? Are the "facts" truly based on fact? Is the focus on the major points? Does the report include ambiguities that could be misinterpreted? Is the report written in logical progression? Are mechanics appropriate?
5
Q
SOAP notes
A
Subjective: non measurable info
Objective: measurable findings
Assessment: assessment of session (conclusions, recommendations)
Plan: plan for next session
6
Q
Writing Assessment Report
A
Identifying information Over/background presenting complaint/status Histories Assessment info: artic/phono, language, fluency, voice Dysphagia Oral-facial exam Hearing Summary Recommendations SLP name and signature
