SHS 412 Exam 2

written case history

where is the first place you can gather information before an assessment

yes

can you screen an individual WITHOUT written consent

Yes

is screening different than an evaluation

FALSE, it is NOT diagnostic

t/f: screening is diagnostic

1. screen for hearing

2. screen for speech and language issues

3. schedule evaluation

order of preassessment

refer

if they fail a hearing screen, you will ___

no

will the client be test if there are no indicators that they have problems during the speech and language screening?

screened: voice, fluency, production

not screened: literacy

what is and is not screened during screening for speech and language issues

Yes

do you have to have written consent for an evaluation

written case history

____ is the beginning point of understanding the communication needs of your client 

true

t/f: The case history is completed PRIOR to the assessment 

1. The respondent may not understand the terminology on the case history form

   1. There may be language differences 

   2. The respondent may be illiterate

2. Insufficient time may have been provided to complete to case history 

3. Respondent may not know certain information 

4. Time may have elapsed between the onset of the problem and the speech evaluation that you are to conduct 

5. Other events may limit the caregivers ability to recall information 

6. Cultural differences 

   1. Respondent who have english as their second language may not understand the questions you are asking 

Reasons the information provided on the case history can be limited:

yes

is it okay to modify during initial assessment period or have the client come back

the clinician who is conducting the assessment

who will read all the information contained within the case history to determine the testings methods to be employed and all other factors pertaining to the assessment 

ethnographic interview 

Allows clinician to understand and appreciate the communication concerns of the client or their caregiver

before assessment

when is ethnographic interviewing conducted

• conversational manner

• open ended questions

characteristics of an ethnographic interview

true 

t/f: During the pre assessment interview, you can move on to assessment if youre going to do a criterion referenced assessment 

ethnographic and intake

preassessment interviews

before

intake interview is conducted ___ the assessment

• Other SLPs

• OTs

• Psychiatrists 

• Doctor 

• Audiologist 

• Others

during the intake interview, You also hear from other professionals such as:

1. The history or the ideology of the disorder

2. Associated social, medical, or educational problems 

3. Treatment histories and the outcome of treatment 

4. The prognosis for improvement 

5. Treatment options

   1. The information from other professionals can lead to a biased view of the client’s condition

   2. It is very important to maintain an objective position as you are assessing 

during the intake interview, hearing information from other professionals can help identify:

true

t/f: the information from other professionals can lead to a biased view of the client’s condition

objective

when acquiring information from other professionals during the intake interview, It is very important to maintain an____ position as you are assessing to eliminate biased views of the client’s condition

after the intake interview

when are you ready for the assessment

you convey the results to others

after the assessment, you ___

1. The information giving conference: post assessment interview

two main ways to convey results to others after assessment:

1. Bring the caregiver or parent back to assessment room

2. Tell them whether or not the assessment gained or revealed the right amount of information or if the client needs further testing

3. Describe the client’s behavior during the assessment 

4. We will discuss the findings and the diagnosis

   1. Keep the language easy to understand 

5. We will inform the caregiver or patient that we will provide a written report and it can be discussed 

6. Discuss treatment options: does the client need to come to therapy, how long, etc

7. Summarize the findings and ask if they have any questions

   1. To summarize, describe the outcomes from assessment and the steps that will be taken going forward

what does the information giving conference/ post assessment interview entail

yes

is the diagnosis discussed in the information giving conference/post assessment interview

after the post assessment interview

when can you write the written report

• Legal document 

• Opinions are not expressed in a written report

• Professional language is used

• The manner of these can change depending on setting and location. 

• Different clinicians will have different styles of reporting information.

what is a written report

false

t/f: opinions are expressed in a written report

yes

can the manner of a written report depend on the setting and location

1. Identifying information

2. Statement of the problem (overview/background)

3. History

4. Birth, developmental,and  health history

5. Speech and language history

6. Educational History 

7. Environmental background and general behavior 

   1. NOW GO TO ASSESSMENT INFORMATION.

8. General behavior observations 

9. Receptive and expressive language 

10. Fluency 

11. Any avoidance of sounds, words, or situations, 

12. The speech rate 

13. Can the client produce more speech when cued

14. Voice 

15. Pitch, rate, loudness

16. Resonance

17. Breath support

18. Muscular tension

19. Stimulability for improved voice 

20. Oral motor examination 

21. Hearing 

22. Speech production

23. Summary

24. Recomendation 

25. Name and signature of SLP

what is included in the written report:

Contains name, DOB, school, address, phone number, caregiver, physician, billing party, diagnostic code, date of evaluation, name of SLP

what goes under identifying information in the written report

Age, who they referred to by, main concerns, who is concerned

what goes under the statement of the problem portion of the written report

1. Information from the case history and intake interview

2. Reports from other professionals 

what goes under the history portion of the written report

1. Condition at birth

2. Certain milestones are mentioned 

3. Any illnesses 

4. Any other conditions or medications that are being taken 

what goes under the birth, developmental, and health history portion of the written report

how the client communicates

what goes under the speech and language portion of the written report

After the environmental background and general behavior

when do you move into the assessment information in the written report

1. Including pragmatics 

2. Some clients will have literacy and cognition

what goes under the receptive and expressive language portion in the written report 

types of fluency and disfluency

what goes under the fluency portion in the written report 

if the client has a feeding problem

what goes under the stimulability for improved voice portion in the written report 

1. Report structures and or functions that affect speech and language production or swallowing 

2. If the client is nonverbal and you are assessing for AAC, you want to know about arm and hand movements

what goes under oral motor exam in the written report 

1. Hearing screening or audiological assessment 

2. History or middle ear infections 

what goes under the hearing portion in the written report

Intelligibility, articulation errors, phonological processes

what goes under the speech production portion in the written report 

yes

if a team did the assessment, are all signatures needed?

 infants at birth to toddlers up to age three

what age is the Individualized family serviced plan (IFSP) for

Individualized family serviced plan (IFSP) and Individualized educational plan (IEP)

documents used to describe the disabilities and needs of a child’s services to be provided and both emphasize the importance of family participation

a little before a child turns 3

 when will the public schools will begin the process of writing the IEP for services in the public schools

Individualized family serviced plan (IFSP)

Written document for early intervention 

• Early intervention is provided to infants and toddlers with a disability or a developmental delay

• In MS, these early intervention services are provided through the health department 

• The IFSP and the IEP are written by a TEAM

• Each team member will provide info on their area of expertise in the document.

• Info from the family will also be on the document. These are rough drafts.

• All TEAM members meet and finalize the document (family, OT, SLP, Teacher, etc)

Components of IFSP:

false (its a team)

t/f: a SLP writes the IEP and IFSP

team

The IFSP and the IEP are written by a

• Parent service coordinator

• all professionals who evaluated the child

• All professionals who will provide the service 

IFSP team includes: 

1. Present level of functioning and needs in the areas of physical (motor), cognitive, social (social-emotional), communication, and adaptive (self help)

2. The description of the services

3. The results and outcomes expected

4. Who will pay for the services

5. The name of the service coordinator 

6. The transitional steps to be taken before the third birthday from an intervention into another program, typically public schools (but ultimately its the parents choice)

7. Written consent for services from the parents 

8. All the team members will sign the document (legal document)

Every IFSP must include the following information:

Individualized educational plan (IEP)

Document for services in the public school 

special education services

____ are coordinated through local school districts under the direction of the state board of education

Individualized educational plan (IEP)

is the written document that describes the services and educational plan that best meet the needs of the child

TEAM composed of a representative of the school district 

IEP is written by a

1. The present level of functioning and academic performance 

2. Measurable goals 

3. All assessment information including the diagnosis 

4. The description of the special education services and other services the child is to receive 

   1. Includes the frequency of services and amount of time of services 

5. How progress toward the goals will be measured and when progress reports will be provided

   1. Typically provided when report cards are provided, every 9 weeks 

6. Amount of time child will be separated from his peers  

7. Whether or not the child will participate in state wide testing

8. Accommodations 

9. The start date, the duration of the services, the frequency of services, and location 

10. Whether or not the child will use AAC

11. Diploma expectations

12. Transition plans 

13. The written consent for services

    1. Until its signed, its a draft document

    2. Before anything can be modified, the WHOLE team has to get back together

    3. amended annually 

14. The signatures of all the team members 

• If there is not an academic need for the services, the services cannot be provided

Each IEP contains the following information:

the whole team signs it

the IEP written document is a draft until

WHOLE team has to get back together

before anything in the IEP document can be modified, the ___

annually

when is the written document for IEP amended

no

can IEP services be provided if there is not an academic needs for the services

clinical correspondence

letters or reports written to other professionals 

written consent

in order to send clinical correspondences to other professionals, we have to have ___

clinical correspondence letters

Most common type are referral letters (to OT, PT, Psychologist, ENT)

• Should be written in a concise form 

1. State when you evaluated client

2. state reasons why you are referring clients for examination by the professions to whom you are writing the letter

3. end with requesting that the professional convey his results of his examination 

4. Thank you 

Content of clinical correspondence letters 

• Subjective: 

  • cant measure 

  • State clients behavior or condition when they arrive (ex: the clients dog had died before they came, sinus infection)

• Objective

  • Measurable 

  • State goals 

• Assessment

  • Combination of subjective and objective information 

• Plan

  • Ex: client will continue therapy on Thursday 

what does SOAP stand for

SOAP notes

Written after the assessment and after each treatment/therapy day 

no, but Therapy sessions will be documented in every setting

are SOAP notes written in every setting

Results of recording a session 

SOAP notes come from the

true

t/f: You must document you have worked on the goals and have established in the written documents

you can receive sanctions from some agencies (ex: medicade)

if you dont document you have worked on the goals and have established in the written documents, what can happen?

1. Cultural groups have differing views of a disability and intervention

2. Cultural groups hold diverse views of a woman's role in society 

3. Cultural groups hold different views of familial authority

4. Names and titles appropriate to use during communicative exchanges may vary among different cultures 

5. Members of a cultural groups maybe uncomfortable with common case history and interview questions 

6. Members of cultural groups maybe uncomfortable with some of our traditional testing

7. Individual achievement is viewed differently among cultural groups

8. Cultural groups hold differing views about a child's behavior in the company of adults 

9. Cultural groups maintain different views about the use of eye contact in communication 

10. Cultural groups view time differently 

11. Cultural groups express disapproval in varying ways

12. Perceptions of personal space may vary across cultures 

13. Certain cultural groups expect varying amounts of small talk before engaging in the business at hand 

14. Some cultural groups harbor generalized mistrust of other cultural groups

Cultural Communication Differences:

1. Grammatical structures are not the same

2. Words are pronounced differently 

3. Vocabulary varies in different languages and sometimes different dialects of the same language

4. Dialects: linguistic variations that are adhered to by identifiable groups of people

speech-language differences:

dialects

linguistic variations that are adhered to by identifiable groups of people

Cultural competence

Enables clinicians to serve all clients with knowledge, respect, and dignity, regardless of a client's cultural differences

true

t/f: to accomplish cultural competence, a clinician must have awareness and willingness to examine personally held beliefs and biases 

true

t/f: Developing cultural competence is an ongoing process that requires continual self-assessment and an expanding understanding about other cultures

ASKED

Conceptual model for gaining cultural competence 

• Awareness: am i aware of my biases and personally held -isms

• Skill: do i have the skills necessary to conduct a speech language assessment in a culturally sensitive matter 

• Knowledge: do i know the world views of different cultures, particularly as they pertain to health care 

• Encounters: do i have meaningful and transforming experiences with people from cultures different from my own

• Desire: do i want to engage in this humbling process of cultural awareness and self-examination

what does ASKED stand for

1. The clinician will need to assess speech language abilities in both primary langue
   and english 

2. Side by side comparison of the findings in both languages is the only way to
   differentiate between speech language disorder and speech language difference

3. Considerations specific to the assessment of CLD clients:

   1. Use culturally appropriate assessment materials

   2. Assess speech language abilities in the primary language and in english. 

      1. Test one language at a time 

   3. Be prepared to modify the assessment plan as more is repealed about the
      Clients abilities and needs

   4. Use the services of an interpreter.translator if needed

   5. Be sensitive and respectful when meeting with clients or caregivers 

      1. Try to help them feel as comfortable as possible. If they are

      2. Uncomfortable, they may not return for future appointments 

how an assessment of culturally linguistically diverse client can differ from other assessments

Side by side comparison of the findings in both languages is the only way to
differentiate between speech language disorder and speech language difference

How to determine if a client has a speech/language impairment or a language difference 

1. Difficulty learning both languages 

2. Atypical nonvernal communication

3. Idiosyncratic and nondevelopmental verbal communication errors

4. Family history of a language learning disability 

5. Slower development when compared to siblings

6. Difficulty expressing basic needs

7. Difficulty with peer interaction

8. Difficulty asking and answering questions

9. Difficulty conveying thoughts ina logical manner

10. Tendency to repeat what is heard 

behaviors or signs that are more indicative of a communicative disorder versus a difference:

true

t/f: standard procedures are to prevent infection

1. Use proper hand hygiene practices

   1. Sterilizing, washing hands between clients and immediately before or after touching bodily fluids

2. Use personal protective equipment

   1. Wear gloves, masks, eyewear, or protective clothing when there is an increased possibility of exposure to infectious material 

   2. do not use single use equipment more than once 

3. Follow respiratory hygiene and cough using etiquette practice 

4. Ensure appropriate client placement 

   1. Client needs to be isolated as much as possible to prevent the spread of infection 

   2. Not possible in every setting 

5. Clean and disinfect the environment 

   1. Disinfect all materials 

The centers for disease control and prevention describe standard precautions that apply to all health care settings: 

• Disposable gloves

• Stop watch

• Small flashlight 

• Tongue depressor

Four pieces of equipment you MUST have during the oral mech exam:

true

t/f: The oral facial examination should be conducted as part of EVERY assessment for communication difficulties and swallowing

oral mechanism exam 

used to to examine and identify structural and functional factors associated with communication disorders 

t/f: during oral mech exam, you want to examine anything that appears outside of what would be considered normal as well as function

true

t/f: You only refer what you considered abnormal if it impacts function in the oral mech exam

a working knowledge of the anatomy and neurological psychologic basis of the oral structure

In order to thoroughly assess the function and structure of the oral mechanism, you must have

1. Color of tongue, palate, and pharynx 

2. The heights and width of the palatal arch 

3. Symmetry of face: 

4. Deviation of tongue or uvula:

5. Enlarged tonsils 

6. Mouth breathing 

7. Missing teeth 

8. Poor intraoral pressure 

9. Prominent rugae

10. Short lingual frenum

11. Asymmetrical or absent gag reflex 

12. Weakness of the lips, tongue, or jaw

Things you might observe during an oral mech exam

paralysis/paresis

what does a grey color of the tongue, palate, and pharynx indicate

excess blood flow or feeding

what does a blue color of the tongue, palate, and pharynx indicate

can be at the border of the hard palate or velum and can indicate a submucous or submucosal cleft 

what does a white color of the tongue, palate, and pharynx indicate

indicate a palatal fistula or a cleft

what does an abnormally dark/transparent on hard palate indicate

MAY (not always) interfere with production of palatal lingual phonemes

Wide/high palate can indicate