Term
| Three main purposes of the diagnostic report |
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Definition
1) Acts as a guide for further services to the client
2) Communicates the clinician's findings to other professionals and the client/family
3) Can be used as research documents |
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Term
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Definition
1) Statement of the problem
2) Background information
3) Evaluation findings
4) Clinical impressions
5) Evaluation summary
6) Recommendations and treatment plan |
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Term
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Definition
-In background info
-The client is here because...
-Who referred them
-Distinguish between client's complaint & referral source's complaint |
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Term
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Definition
-Medical history
-Educational history
-Family history
-Developmental history
-Information from other sources
-How you got information |
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Term
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Definition
-Assessment tools you used & results
-Short intro paragraph
-Data |
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Term
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Definition
-General statement
-Who was there
-Alertness/cooperation |
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Term
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Definition
-Interpreting results
-This suggests/shows that
-How it affects everyday life
-Data based |
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Term
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Definition
-Short paragraph
-Most significant information from findings
-What communication disorder?
-What are primary features of disorder?
-Probable cause
-Prognosis |
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Term
| Recommendations and Treatment Plan |
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Definition
-Short paragraph
-Initial goals
-Therapy approach
-Frequency & duration of treatment
-Recommendations for referrals |
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Term
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Definition
1) Be straightforward
2) Be objective
3) Give examples
4) Watch your wording
5) Avoid ambiguity
6) Edit carefully |
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Term
| Components of a prognosis |
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Definition
-For what?
-Improvement of what?
-Good/positive/fair/guarded/poor
-Based on |
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Term
| Considerations for a prognosis (8) |
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Definition
1) Age
2) Length of time impairment has existed
3) Existence of other problems and strengths
4) Stimulability
5) Prior response to therapy
6) Reactions of significant others
7) Client motivation
8) Research on improvement for each specific disorder area and the aspect of communication you expect will improve |
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