CSD332- quiz 3

Diagnostic report

written record that summarizes relavent information the clinician obtained

Purpose of report

1. its a guide for further services for clients

2. its an official record of the meeting

3. it communicates clinicians findings to other professionals

4. it can serve as a document for research

why are clinical reports important

its the principle in which we relay information to other professionals

ways to organize the diagnostic report

1. SOAP notes (medical setting)

2. IEP (school setting)

S-

Subjective- interview and case history information

O-

objective- test results (numbers, statistics, SD)

A-

Assessment- summary and impressions

P-

Plan- recommendations

IEP

a student focused plan advised by a team of teachers, administrators, spoecial educators, and parents

IEP should answer…

1. whats the problem?

2. Wheres the student now?

3. who will do what with the student and how often?

4. when and how will progress be measured?

Criteria that should be used to judge a diagnostic report

• is it accurate?

• is it complete?

• is it efficiently written?

• prepared promptly?

diagnostic report format

1. Routine information: name, DOB, school age, eval date, clinician name, referral source

2. Statement of problem: make a statement about the problem, whats the complaint? EX: mrs. smith was concerned about joeys speech intelligibility

3. Historical info/case history: include information rom referral letters, case history, clients development, medical history, education history, and family history

4. Evaluation: name of test and the areas assessed, test results, information that is presented and not interpreted. EX: joeys standard score of the vocab subtest was 112 which placed him in the 75th percentile

5. Clinical impressions: summarize the impressions, should be able to answer…what type of speech/language error is occurring?, how severe? whats the cause?

6. Recommendations: specific/brief, dont recommend specific evaluations to workers in other professions, include patient/family plan

confidentiality

to release any information you the the clients permission in writing

What does the exit conference include

• what was done today/measured

• what were the findings in relations to the norm or standards

• whats the outlook for improvement

• what is recommended to be done

Questions we need to ask when doing a exit conference

• do i have enough information to answer the diagnostic question with confidence?

• have new areas been identified during the evaluation?

• how do you organize information so the patient and the family will understand the problem?

• how do we present the information so the client regards the information as satisfactory?

• do i know enough about the problem to recommend therapy or no?

• what other diagnostic procedures or examinations might be useful to them?

• Have i given them a chance to ask questions, and express their feelings?

clinicians and counselors

the counseling function begins in the diagnostic setting and extends throughout therapy

what 3 things do counselors need to do?

1. Help- help the client/family discuss areas of concern

2. Provide- provide motivation

3. Offer- offer support

educating the client will…

1. enable patients to understand the results

2. understand the general features of the disorder

3. understand the implications for management

making recommendations

• general recommendations

• recommendations that change someones behavior

• recommendation to stop a behavior

• no therapy is recommended

• recommendation to another discipline

Final step of an exit conference

secure confirmation of the patients intent to carry out recommendations

immediate and delayed action