Clinical Reports: Writing and Prognosis

• Clinical reports are written reports that vary in length.
• These reports inform the reader of the client's medical status, progress, and any change of status.

Well-Written Clinical Reports

• Well-written clinical reports are culturally sensitive, ethical, and provide a snapshot of the client's overall communicative status.
• They state an appropriate prognosis and recommendations without misleading information.
• A prognosis statement projects how well a client will progress in therapy, given their communicative status, medical/mental health, and support system.
• In articulation cases, prognosis depends on stimulability and oral motor strength.

Clinical vs Composition Writing

• Clinical writing is for multiple audiences and impacts beyond grades, used to qualify individuals for federally funded disability programs, and is filled with professional specific genres.
• Composition writing is longer than technical writing, often asks the student to assume the identity of a researcher, generally has one audience (professor), is written for a grade.

Clinical Writing Tips

• Avoid conversational style, use correct spelling, grammar, and punctuation; write complete sentences, and write in the third person.

Clinical Report Purposes

• Summarize client status.
• Outline the initial treatment plan.
• Monitor client performance throughout treatment.

Diagnostic (DX) Report Components

• AAMU Dx Reports have essential components.
• Include identifying information so that any information can link the patient to the report, such as name, date of birth, address, age, diagnosis, nationality, phone number, etc.
• Include a statement of the problem stating why they are here in paragraph form, including full name and age, location and date of initial evaluation, reason why the client is seeking clinical intervention, current communication status/issues as viewed by the historian/reporter (normally parent), referral source; the statement of problem is generally short (3-5 sentences long).
• Include background information, i.e., case history (states in paragraph form): prenatal and birth history, developmental history, pre-morbid history, any previous treatments, and family/social and educational history
• Observation and Assessment Results MUST have a statement for each area of communication: Peripheral Oral Examination, Audiological (screening), Articulation, Language, Fluency, Voice
• Summary of Findings summarizes collected information, describing strengths and weaknesses in a "snapshot" of overall status.
• Prognosis is a short statement of the clinician's expectation of client performance in therapy, considering communication, medical/mental status and support system.
• Recommendations state whether treatment is needed based on DX results: Focus/direction and frequency, follow up appointments.
• Long Term Goals states overall communicative objective, reflects how client is to perform at the end of ALL treatment or at the end of a specific period of time, contains the 3 components of BO
• Short Term Goals states client's short term objectives or goals during a given semester—”starter goals”; must be obtained before the LTG/O is achieved, contains the 3 components of a BO

Initial Tx (therapy) plan

• Comprises of LTO/G and STO/G objectives based on diagnostic findings and pretreatment baseline results.
• Developed immediately after testing is completed.
• States what the client is targeting in therapy.

Lesson Plans

• Includes the following 7 major components:
• Long Term Objectives
• Short Term Objectives
• Procedures-The step-by-step actions the clinician will execute to provide opportunities for the client's target behavior to occur
• Cues-what the clinician will do to actually train client's target behavior and correct errors—the teaching of targeted objectives -clinician support
• Reinforcement-what the clinician will do to shape or condition client behaviors i.e. verbal praise; stickers, tokens etc. Reinforcement is what aids in changing undesirable behaviors
• Materials- manipulatives that clinician will use to stimulate client's response i.e. games, magazines, etc.
• Tally/Data-client's measurable performance on a given task (+=correct, -= wrong, c=needed help)

Progress Notes (SOAP notes)

• Progress (SOAP) notes vary in length and are written after each therapy session and/or weekly (AAMU CSD Clinic)
• (This is where you write about the lesson plan technically)
• Progress (SOAP) notes have 3 important functions:
• Enable monitoring of the tx program on a continual basis to implement any necessary changes immediately.
• Provide information on a daily/weekly basis to other professionals who also may be working with the client (OT, Social worker, PT, MD, etc).
• Facilitate continuity of treatment by allowing another clinician to provide services to provide services in the event of unexpected clinician absence.
• SOAP Notes are divided into 4 components:
  • S: Subjective Data: Reports clinician's observations regarding relevant client behavior that will directly affect therapy progression (session)-temperament, physical condition, motivation, behavior, symptoms and complains
    • O: Objective Data: Reports...Data that can be measured.
    • Client's performance toward ALL stated STGs as documented on the lesson plan in measurable objective and skilled terminology (measurable and observable)
    • Test findings, scores
    • There will be times when all STGs will not be addressed in a given session due to time constraints. If a goal from the lesson plan was not targeted, state the reason.
    • A: Assessment: Reports the clinician's interpretation of the client's condition or level of progress Interpretation includes (get down into the “we”):
      • Clinician's analysis regarding client's performance on previous therapy sessions
      • Indicates client's progression or regression on stated goals
      • Professional opinion made by the clinician about the effectiveness and appropriateness of the tx plan
      • Justification statements for continuing tx
      • Meaning of test scores
    • P: Plan: Reports specific measures designed to manage the client's problem.
      • Includes: Recommendations to continue therapy or assessment Justification for current therapy needs based on the information documented in the "O" and "A" sections of the SOAP note
      • Proposed therapy targets for the next session
      • Details of modifications to the treatment plan

Summary Report

• Summary reports documents a client's performance on goals and objectives outlined in the ITP and lesson plan, implemented over the course of treatment (end of each semester)
• Contains 4 major sections: Identifying Information \t- Results of Therapy- Summary of client's performances on all objectives during a given semester Clinical Impressions (prognosis) Recommendations (Average the last three performance to get how their progress)

Other Clinical Forms

• The Education of All Handicapped Children Act (PL 94-142) was passed in 1975 to ensure that all children with special needs, ages 3 – 21, received a free, appropriate public education; updated in 1997 through authorization of PL 105-17, the Individuals with Disabilities Education Act (IDEA).
• Based on these public laws, each child with special needs must have an annual written IEP that documents the need for the provision of special education services and to identify specific areas for remediation.
• Content of IEPs:
  • Present levels of performance- current status in all pertinent areas of development and education; client's present test scores and clinical analysis of observed performance
  • Annual goals – long term projections as to what the client will accomplish during a fiscal school year
  • Special education and related services – identifies special services the child needs to obtain, including the type and frequency of services
  • Placement recommendation and justification – the specific educational setting in which a child will be placed = least restrictive environment (children with disabilities should be educated with children with no disabilities); placement somewhere other than in a regular classroom in the child's school district must be accompanied with a written rationale (ex. Jacoby at Jones Valley)
  • Initiation and duration of services – dates that services will began and projected duration of services; duration is typically 1 year because IEPS are reviewed annually; reevaluation is conducted as conditions warrant, but must be done at least every 3 years (as an slp we tend to do it every year)
  • Related Services- the other disciplines involved in the IEP process. Individually based.
  • Due Process: Provided by IDEA that legal and procedural safeguards throughout the educational placement process, including time lines for completion of each step, parental notification and consent, and an appeal system to ensure due process for all parties involved. Parent or guardian must be notified of ANY changes; due process provides a formal mechanism for parents to protest decisions they consider inappropriate or unfair to their child.

Individualized Family Service Plan (IFSP)

• Individualized Family Service Plan (IFSP) was enacted in 1986 to include children between birth and 3/ technically 2 11 months years old in free and appropriate education.
• Development of an IFSP is similar to IEP but focuses on the family unit rather than just on the child
• Includes children considered “at risk” where IEPs are only for those children who have recognized disabilities
• Allows for services to be provided outside of school arena (social welfare, respite care)
• Contains provisions for home-based instruction, family ed, and counseling
• Reviewed every 6 months, instead of annually (IEP)
• Contents of IFSPs, in addition to the sections on the IEP include areas addressing:
  • 1. Family strengths and needs describes the family's strengths and weaknesses in enhancing the development of the child, a statement of child's disability impacts family functioning, and family members may also specify their desired levels of involvement in intervention Case manager identifies one person, a professional, most relevant to the needs of the infant and family; case manager is responsible for the development of the ISFP and for its implementation, coordination, and monitoring of all services; Slps are usually the case manager for infants and children who have communication and oral-motor deficits
  • 3. Transition– outlines the procedures that will be employed to facilitate the transition to services provided under PL 94-142 if the child continues to need special services after 2;11

Clinical Reports Overview

• Professional Correspondence should be written clearly and concisely, with correct grammar, spelling, and punctuation, including release of information, making referrals to other professionals and acknowledging referrals to colleagues
• It is essential that clients authorize the release of information, giving consent neither verbally or in writing without a release. Clinical reports are ALWAYS WRITTEN IN THIRD PERSON

Chronological Age Calculations

• Typical date is recorded as:
  • February 11, 2025
• However when calculating chronological age we record the year, month, and day
• Of the test date, subtracted by the client's age.