Term
| Why gather a clinical history |
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Definition
Obtain background history on client and disorder
Avoid approaching clinical event blindly |
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Term
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Definition
Begin gathering information
Begin to plan assessment
Begin to develop clinical hypothesis |
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Term
| Begin planning assessment that is conductive to: |
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Definition
Age
gender
culture
background of client |
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Term
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Definition
| Plan clinical history in such as way that you will have all the information needed to understand clinical issue |
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Term
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Definition
Determine why and how the appointment was made
Obtain written authorization for release of info
Question client/family member (interview)
Clinical is able to form impression on need, restrictions and motivations |
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Term
| Pre-Assessment information should include: |
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Definition
Written case history
Interview with client/caregiver
Information from other professionals
SLPs need information that reveals:
Health, social, developmental, educational and occupational challenges |
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Term
| SLPs need information about: |
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Definition
Onset of problem
Development of disorder
Impact of disorder on person life
Typical/atypical nature of disorder
Previous treatments
Success of previous treatments
Family & social relationships
Daily life activities
Academic patterns
Health- developmental milestones, illnesses, |
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Term
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Definition
What you ask and how you ask questions
HOW-manner you talk
No right way to ask questions-but there are techniques |
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Term
| Designing the Assessment setting/mood |
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Definition
Be friendly and polite-yet professional
Remain focused and able to redirect conversation
Demonstrate your interest
Balance telling good news and explaining bad news
Conduct interview in room of adequate size
Use of language should be mixed with technical and everyday language |
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Term
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Definition
Pace should not be rushed
Clinician should be culturally sensitive
Client history is crucial
Confidentiality must be maintained
Skills needed to obtain comprehensive history is obtained over time |
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Term
| Improving skills in comprehensive history by: |
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Definition
| Practicing, considering clinical needs, observing others, becoming sensitive to needs/challenges of others, studying |
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Term
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Definition
The way questions are ask can influence response
Best questions elicit specific responses
Close ended questions
Open ended questions |
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Term
| Limitations on the interview |
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Definition
Clinician must now how to be supportive and encouraging
Clinician must keep interview on track |
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Term
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Definition
Clinician listens to information verbally and observes for nonverbal
Problem should be discussed until understanding is achieved |
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Term
| Reliability Problems with Case Histories |
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Definition
Client may not of understood terminology on form
Sufficient time was not provided to complete form
May not know or have limited knowledge on certain information
Significant time may have elapsed between onset and assessment
Client’s ability to recall information may be hindered
Cultural differences may interfere |
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Term
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Definition
Opening Phase
Body of interview
Closing phase |
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Term
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Definition
Introduce yourself
Describe purpose of meeting
Indicate how much time the session will take |
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Term
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Definition
Discuss client’s history & current status in depth
Include: developmental, abilities, problems, medications, family, social, education |
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Term
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Definition
Summarize points from interview
Express appreciation for help
Indicate steps that will be taken next |
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Term
| Information from other professionals |
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Definition
Helpful in gaining a better understanding of disorder/diagnosis
May identify history of disorder, concomitant medical, social, educational or family problems
Prognosis implications
Treatment options/alternatives |
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Term
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Definition
Remain objective
Avoid developing biased view of client based on others information
Depend upon your direct observations and interactions with client |
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Term
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Definition
Health insurance portability and accountability act
Privacy rules require you only request info that is necessary
Written permission is required |
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Term
Linguistic diversity
English as 2nd language |
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Definition
Use translator
Schedule planning conference
Familiarize translator with purpose of evaluation
Familiarize translator with relevant paperwork |
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