Alabama A&M University
Speech-Language-Hearing Clinic
Diagnostic Report Grade
Student Clinician:Areas to be Assessed
***Note: If maximum number of points is not obtained, see information in the left column and make the necessary revisions within 3 days. Then resubmit the revised document to the attending clinical supervisor for final approval. Highlight all revisions when
resubmitting document. Maximum Points Achievable Week of: Client:
Document is submitted within one week of completing testing (note: exceptions for tardy work will need to be accompanied by a University approved excuse- See
Sanoyia Williams in CCS Rm106 or submit a doctor’s excuse or funeral announcement to the attending supervisor).
**Note: Technical and personal computer issues are
the responsibility of the clinician. In case of technical failure of a personal computer, computers are available in the LRC and in the computer lab for student use. Students should plan ahead (complete paperwork early- i.e. 12-24 hours prior to submission deadline) in order to allow time to use library, computer lab, or family/friend computers in the event of technical failure. Tardy submission of paperwork due to technical or personal issues will be reflected in the weekly grade.
10 Points- Document is submitted before 12:00 noon on Friday for the following week 0 Points- Document is submitted after 12:00 noon on Friday for the following week
10
The entire document uses font size12 and Ariel style
text. Separate each informal/formal procedure/test by a
space (refer to Diagnostic Report Samples on-line on the CSD website).
10 Points- See column to the left
5 Points- Varying font size or style is used throughout the document and/or formatting for the document does not follow samples provided on-line on the CSD (see column to the left) 0 Points- Varying font size and style are used throughout the document and other formatting issues are present (see column to the left)
10
Document is free of typing, spelling, and grammatical errors
***Note: Use grammar check and spell check at all times and proofread document before submission **Names of therapy materials/books and/or diagnostic tests should be underlined or italicized. The first time a test is listed use the full name. Subsequent references to the test can be abbreviated, but still need to be underlined or italicized:
Webber’s Jumbo Articulation Drill Book Goldman-Fristoe Test of Articulation-2 GFTA-2
15 Points- Document contains no more than 2 typing, spelling, and/or grammatical errors. See column to the left
10 Points- Document contains 3 typing , spelling, and/or grammatical errors 5 Points- Document contains 4 typing , spelling, and/or grammatical errors
0 Points- Document contains more than 4 typing , spelling, and/or grammatical errors
Header information on page 2 and beyond is filled in
(refer to Sample Diagnostic Reports on-line on the CSD 516 website) and is accurate (client initials, semester/year, and page numbers).
5 Points- Header information is accurate
0- Inaccurate information is present in header (client initials, semester/year, and/or page numbers are incorrect)
5
All fields pertaining to identifying information (Client name, DOB (date of birth), Age, Address, Telephone number(s), Informant (person who filled out case history form), Examiner, Date(s) of Evaluation (list all dates that testing took place), Diagnosis, Referred by, Client’s Occupation (put N/A for a child) and Supervisor are accurate. Refer to Sample Diagnostic Reports on-line on the CSD 516 website.
5 Points- Identifying information is accurate.
0 Points- One or more errors are present. See column to the left
5
The statement of problem is generally short (3-5 sentences long) and states in full paragraph form: *Full name and age of client
*Location and date of initial evaluation
*Reason why client is seeking (or was referred) clinical intervention
*Current communication status/issues as viewed by the historian/reporter (normally parent if client is a minor) *Referral source
Example:
John Doe is a 46 year old male who was seen at the Alabama A&M University Speech-Language-Hearing Clinic beginning September 18, 2009 for a complete communication evaluation due to difficulty speaking after a CVA/stroke. Mr. Doe was referred by his physician, Dr. Weeks. John currently communicates using simple words and often complains of memory loss per Mrs. Doe (wife), who served as historian.”
5 Points- The statement of problem includes all necessary information and is written in the appropriate format (see column to the left)
0 Points- The statement of problem is not complete (is missing one or more of the necessary components listed in the column to the left)
5
Background Information states in paragraph form the following (hx= history):
*Prenatal and birth hx
*Developmental hx (i.e. milestone development) *Pre-morbid hx (i.e. communication status prior to onset of problem when applicable)
*Any previous dx, or tx- specifically what has been diagnosed in previous examinations
*Recommendations made from previous professionals *Family, social, and educational hx
5 Points- Background information includes all necessary information and is written in the appropriate format (see column to the left)
0 Points- Background information is not documented according to protocol/appropriate format and/or is incomplete (is missing one or more of the necessary components listed in the column to the left)
Observations and Assessment Results contain all of the
informal and formal diagnostic procedures/tests performed on the client. Must have a statement for EACH area of communication. There are 6 main areas to
be assessed:
1. Oral Peripheral Exam
2. Audiological (Screening)- if <3.0 y.o. -audiologist 3. Articulation
4. Language 5. Voice 6. Fluency
Each area should be in bold print with results stated in paragraph form. Refer to Sample Diagnostic Reports on-line on the CSD 516 website. Information for formal speech-language tests should be presented in table form (for tables refer to diagnostic chartsR fil)e. Separate each procedure by a space, for example:
Oral-Peripheral Exam
An oral-peripheral exam was administered….
Hearing Screening
A pure tone audiological screening was administered…
Articulation
The clinician administered the Goldman-Fristoe Test of
Articulation-2 (GFTA). The results were as follows:
GFTA-2 Sound in Words Subtest Raw Score Standard Score Percentile Rank Age Equivalent 21 101 48 3-6
**Names of diagnostic tests should be underlined or italicized. The first time a test is listed use the full name. Subsequent references to the test can be abbreviated, but still underlined or italicized.
****See note in column to the right Webber’s Jumbo Articulation Drill Book Goldman-Fristoe Test of Articulation-2 GFTA-2
**Note: Typical components to address when reporting
scores from standardized tests include: Raw Score
Standard Score Percentile Rank
Age Equivalent and/or Grade equivalent
(Standard Score Confidence Interval and/or Percentile Rank Confidence Interval may also be reported)
**Report test scores in table form
15 Points- Assessment results are scored and reported accurately-All 6 areas of communication are addressed-See column to the left
10 Points- One or more of the 6 areas of communication is not addressed
0 Points- Assessment results are not scored and/or reported adequately or correctly
Summary of Findings contains an explanation of what
the test findings mean in terms of normalcy/disorder
stated in paragraph form. The client’s weaknesses and strengths are also documented. For example:
Based on the formal and informal test results, Johnny exhibits a receptive and expressive language disorder. Johnny’s scores on the PLS:4 reveal a total language standard score of 50 (> 3 standard deviations below the mean/average standard score of 100 with a range of normalcy of 85-115) and age equivalents ranging from 1.9-1.11 versus his chronological age of 5.9. During the assessment process, Johnny was able to identify some familiar pictures, objects and actions (e.g. “Show me ‘running’”) when given object or picture stimuli. He was able to inconsistently follow a few simple commands (e.g. “Point to your nose”). However, he had great difficulty using more than one word utterances and answering simple “Wh” and “yes/no” questions. The clinician also noticed that Johnny displayed a very short attention span and had difficulty attending to a task for longer than one minute.
10 Points- See column to the left
5 Points-A diagnosis is rendered without sufficient documentation of assessments/test results that led to clinical impressions. Areas of weakness and/or strength are not adequately addressed
0 Points- The professional opinion rendered (interpretation/meaning of test results) is not accurate and/or is not supported by observable, measurable data/behaviors.
10
The Prognosis statement (generally one-three sentences long) addresses the prognosis for improvement (i.e. the prognosis for meeting therapy goals) and the reasons for the clinician’s conclusion. For example:
The prognosis for Anthony Brown to improve his oral language skills is good due to strong parental support and school support.
OR (for a client with normal assessment results) The prognosis for Susie’s continued speech-language development is very favorable due to **fill in**(e.g. her enrollment in a language rich pre-school environment and strong family support).
5 Points-The prognosis statement is accurately and thoroughly documented using the appropriate format (see examples in column to the left).
0 Points- The prognosis statement is not accurately and thoroughly documented (see examples in column to the left).
5
Recommendations is a statement that addresses: *Whether treatment is warranted (and if so, where and how often services should be provided)
*What areas of communication need to be addressed For example:
It is recommended that Johnny Jones be enrolled in speech therapy for the Fall 2012 semester at the Alabama A&M University Speech-Language-Hearing Clinic for two fifty-minute sessions per week targeting receptive and expressive oral language skills.
OR
Susie Smith’s speech-language skills are developmentally appropriate; therefore, therapy services are not warranted at this time.
5 Points-The recommendations statement is accurately and thoroughly documented using the appropriate format (see examples in column to the left).
0 Points- The recommendations statement is not accurately and thoroughly documented (see examples in column to the left).
Long Term Goals are BROAD and typically reflect how the client should be performing at the end of ALL treatment. Include a LTG for behavior when appropriate.
A LTG for homework should be included for all clients
served in the AAMU clinic. Refer to Sample Diagnostic Reports on-line on the CSD 516 website.
Long term goals may or may not include a criterion. They begin with the words, “The client will…”
NOTE: Number, order, and wording of each STO must match the ITP and other clinical documents
Examples:
1. The client will attend to a give task and remain seated for 40 out of 50 minutes.
2. The client will correctly produce /r/ in conversation with 90% accuracy.
Note: Articulation/Language Goals should follow this basic order-
Behavior Goal (if needed) Receptive Language Goal(s) Expressive Language Goal(s) Homework Goal
5 Points- Long term goals are broad, documented and numbered correctly and are appropriate for the client. A homework goal is present.
0 Points- Long term goals are not broad, not documented and/or numbered correctly and/or are not appropriate for the client. Homework goals and/or behavior goals (when needed) may not be present.
5
Short Term Objectives are SPECIFIC in nature and are measurable (e.g. what the client can accomplish this semester). STO’s contain 3 components: action, condition, and criterion (refer to Roth & Worthington Chapter 1). Include a STO for behavior when
appropriate. A STO for homework should be included for all clients served in the AAMU clinic. Refer to Sample Diagnostic Reports on-line on the CSD 516 website.
NOTE: Number, order, and wording of each STO must match the ITP and other clinical documents
*Action- statement of the behavior to be obtained
e.g. “will correctly produce /r/”
*Condition-situation under which the behavior is to be
performed (e.g. “in the initial position of words”)
*Criterion -how well the target must be performed-may or
may not be a % e.g. “with 90% accuracy” Example STO:
1a. The client will correctly produce /r/ in the initial position of words following a clinician’s model with 90% accuracy.
OR
1a. The client will follow 2-3 step commands given orally with 80% accuracy.
1b. The client will identify past tense verbs when given picture stimuli with 80% accuracy.
5 Points- Short term objectives are specific, measurable, contain the 3 components of a well written behavioral objective, are documented and numbered correctly, correspond with the long term goal they are paired with (e.g. goals addressing receptive communication are paired with a long term goal that targets receptive communication) and are appropriate for the client. 0 Points- Short term objectives are not specific and/or measurable, not documented and/or numbered correctly and/or are not appropriate for the client. Homework goal(s) and/or behavior goal(s) may not be present when needed.
5
Points: Grade: