Clinical Documents

Diagnostic Reports

Purposes

To indicate whether or not a person needs therapy

To support that recommendation with all necessary data (IDEA requires that all appropriate tests and measures be used in reaching a diagnosis/recommendation)

Basic Parts of the Diagnostic Report

Identifying Information

Summary Statement Background

Information Assessment Recommendations

Identifying Information

“Vital Statistics” about the client Include all information needed Use proper format for order and spacing

Summary Statement

Identify client by name, age, and gender Identify the purpose of the referral Identify the speech/language problems and the

severity of the communication disorder Summarize test data to support your

recommendation

Background Information

Name, age, and gender of client in first sentence Referral source and purpose of referral General History (indicate informant)

Birth and medical history Developmental milestones (child) Speech and language description Home, work, school, social environments

Assessment

Possible areas to include (areas included and not included will vary from one client to the next)

Language Speech Oral Peripheral Motor Hearing

Begin Assessment with General Observations

Client’s behavior and attitude during the evaluation

Reliability of test measures used

NOTE: Put the following areas tested in priority order, most severe problem first

Language

Language Comprehension Language Production

(For formal tests, follow guidelines for reporting results: full name of test, test format, client’s results, your interpretation; for informal tests, also include sample utterances/narratives)

Speech

Phonology/Articulation Phonology Articulation Phonetic inventory Intelligibility

Follow guidelines for reporting formal test results; include samples when appropriate

Speech, cont.

Fluency Voice

Provide examples of disfluencies, speaking rate, etc.

Describe pitch, loudness, voice quality, and resonance

Oral Peripheral Examination

Tongue mobility Lip mobility Palatial mobility Diadochokinetic syllable rates

Describe results of exam in all areas evaluated

Motor and Hearing

Motor: Identify test given and describe client’s performance

Hearing: Describe results of all hearing tests and provide date and location of assessment

Recommendations

Make a general recommendation for or against therapy. If recommended, indicate type of therapy, frequency and duration of treatment, and location of treatment

Prioritize specific areas to be addressed Indicate any further testing or referrals

needed