Assessment in Speech-Language Pathology

Introduction to Assessment

Learning Objectives

  • Discuss goals of clinical assessments.
  • Outline components common to communication & swallowing assessments.
  • Describe importance of the clinical report and principles of clinical writing style.
  • Perform oral mechanism examination on classmate and write up results.

Assessment

  • Assessment = Examination = Evaluation
  • Goals:
    • Observe function.
    • Provide diagnosis.
    • Determine prognosis.
    • Plan treatment.
  • Not just an assessment of functioning, but how it impacts activities of daily living (ADL) and quality of life (QOL).

Common Components of Communication & Swallowing Assessments

  • Case history
  • Screening
  • Speech/language sample
  • Standardized tests
  • Oral mechanism examination
  • Impacts to ADL & QOL

Case History

  • Patient (pt) forms & clinical interview
  • Identifying information
  • Pt’s description of the problem
  • Medical & surgical history
  • Prior SLP services
  • Contextual information
  • Family/living arrangement
  • Verbal & cultural background
  • Educational & occupational background
  • Premorbid skills
  • Pt’s goals for the assessment

Screening

  • Identify need for other detailed assessments
  • Formal or informal
  • Hearing
  • Mental health
  • Other communication/swallowing domains
    • Language
    • Cognition
    • Voice
    • Speech
    • Swallowing

Speech/Language Sample

  • Naturalistic
    • Conversation
    • Picture description
    • Reading short passage
  • Assess speech, fluency, language use, pragmatics

Standardized Assessments

  • Formal assessments with strict instructions on administering and scoring
  • Compare functioning to a large “normative” sample
  • Specific to overall goals of assessment

Impacts to ADL/QOL

  • Formal scales
  • Patient-reported outcomes (PRO)
  • Patient interview

Clinical Writing

  • Importance of clinical documentation: IF IT WASN'T DOCUMENTED, IT WASN'T DONE

Clinical Writing Tips

  • Include observations AND interpretations
  • Differentiate information reported by others vs. that directly seen by your observation
  • Report findings objectively, so conclusions are supported by the data
  • Include information about pt’s strengths and weaknesses
  • Include tips for effective cueing of desired behaviors
  • Write like your report will be read aloud in a court of law
  • Do not overstep your scope of practice
    • E.g., we cannot diagnose Parkinson’s disease, cancer, etc.
  • Consider your intended reader – what do they know?
  • Use professional terminology, but provide explanations/examples so non-professionals will understand
  • Define acronyms/initialisms on first use
  • Write in third person and only refer to yourself as absolutely necessary
  • Be succinct – the fewer words, the better!
  • Include sufficient detail
    • “Pt’s diadochokinetic rates were within normal limits”
    • What was the rate? What are normal limits?
  • Avoid conversational style
    • Instead of: “He just didn’t’ get the point”
    • Try: “He did not appear to understand the task”

Summary

  • Clinical assessments are a critical part of SLP practice
  • Assessments contain common components but are tailored to goal of assessment and patient considerations
  • Oral mechanism assessment is a great place to start!