Information Reporting Systems & Techniques

Week 3

What’s the purpose of clinical reporting?

• summarize

• interpret (SLP ONLY)

• progress

• performance

• prognosis

clinical report writing

• clear, concise, organized

• effectively communicate b/w SLP, Drs, PT, OT, psychologist, etc.

Types of reports

• initial therapy plan

• progress notes

• progress & final reports

What’s the purpose of initial therapy plan?

• outline intended intervention plan

• document client performance

• summarize client status

Key components of initial therapy plan

• identify info

• background info/Pt Hx

• goals & objectives

• reinforcement

• family engagement

• generalization plan

Progress notes serve 3 important functions which are to:

• Enable the clinician to monitor Tx program on a continuous basis & implement any necessary changes immediately

• Provide info. on a daily basis to other professionals who also work w/ Ct

• Facilitate continuity of Tx by allowing another clinician to provide services in the event of unexpected clinician absence

S.O.A.P. Notes: Subjective

Write opinion regarding relevant client behavior or status in a brief statement

Key teaching strategies: Objective

Record data collected for each task during the therapy session

Key teaching strategies: Assessment

Interpret data for current session & compare to client’s previous lvls of performance

Key teaching strategies: Plan

Identify proposed therapy targets for the next session

Other names for progress reports/final reports

• Interim summaries

• Annual reviews

• Discharge reports

• Final summaries

What’s expected from a SLPA?

• Record data

• Screening

• Tx

• Provide assistance in assessments

• Creating therapy materials

• Scheduling of therapy activities w/ approval of SLP

What ages does the Individualized Family Service Plan (IFSP) serve for?

0 months - 3 years (36 months)

504 Plan

For students who don’t meet eligibility for IEP but still need assistance

Accomodation examples

• provide audio recording

• provide in large print

• reduce number of lines per pg

• present instructions orally