Lecture 2 on Complete Assessment PDF

Overview of a Complete Assessment Dr Shabnam Abdoola From Assessment in Speech Language Pathology: A Resource Manual, Seventh Edition By Kenneth G. Shipley and Julie G. McAfee. Copyright © 2025 by Plural Publishing, Inc. All rights re...

Overview of a Complete Assessment Dr Shabnam Abdoola From Assessment in Speech Language Pathology: A Resource Manual, Seventh Edition By Kenneth G. Shipley and Julie G. McAfee. Copyright © 2025 by Plural Publishing, Inc. All rights reserved. Overview Case history Interviews Direct assessment Analysis of findings Writing reports Sharing findings Telepractice Elements of a Complete Assessment Complex process Most assessments involve: ○ Case history ○ Intake interview ○ Internal and external influences ○ Evidence-based assessment approaches ○ Direct assessment of the client ○ Analysis of data ○ Assessment report ○ Sharing findings and recommendations Obtain a Case History Record of relevant information pertaining to past and present concerns Histories ○ Developmental ○ Medical ○ Family ○ Professional evaluations ○ Occupational ○ Educational ○ Sociological Provide a starting point for assessment May be limited due to potential problems Obtain a Case History (cont.) Allergy Awareness Important to be aware of allergens, particularly if it’s being used during assessment or treatment Information from Other Professionals Other SLPs, Auds, doctors, teachers, psychologists, occupational/physical therapists, counselors, etc. May lead to biased view of client’s condition Conduct an Intake Interview Opening phase ○ Introductions ○ Purpose of meeting ○ Structure of meeting Body of the interview ○ Major content areas Closing phase ○ Summarize major points Consider Internal and External Influences Communication is influenced by many variables Internal influences include physical and mental limitations ○ Cognition and communication ○ Motor abilities and strength ○ Hearing and visual acuity External factors can influence the assessment ○ Family environment ○ Linguistic factors ○ Cultural influences Directly Assess the Client Multiple approaches will be employed The more direct assessment information the clinician obtains, the stronger the conclusions will be Choose approaches that will validly and reliably assess behaviors of concern Apply modifications when necessary Account for cultural-linguistic factors Play-Based Assessment Use of toys and activities Following child’s lead Suitable for children with limited English proficiency Assimilate and Analyze Findings Often the most time-consuming portion of the assessment Deep analysis ○ Make diagnosis ○ Determine progress ○ Recommend treatment plan ○ Establish realistic goals Consider client input Score standardized tests Analyze speech-language samples Analyze results of dynamic assessment Analyze observations Consider influences that will contribute to prognosis Make a Diagnosis and Recommendations Goal of assessment Outcomes typically fall within one of these scenarios: ○ Communicative disorder is diagnosed, treatment plan recommended ○ Communication disorder diagnosed, treatment plan recommended, further testing recommended ○ Client performs within normal limits Diagnosis -> clinical label Treatment plan -> intervention strategy Elements of treatment plan ○ Frequency ○ Duration of sessions ○ Environment ○ Goals Write a Diagnostic Report Summary of entire assessment No standard template Contain relevant information ○ Identifying information ○ Overview and initial status ○ Histories ○ Assessment findings ○ Summary of findings ○ Recommendations Well organized, clear, concise IFSPs and IEPs Individualized Family Service Plan (IFSP) ○ Typically for infants and toddlers and should transfer to an IEP Individualized Education Program (IEP) Written documents specific to children from birth-high school Early intervention ○ Services provided to infants and toddlers and their families ○ IFSP developed by a team ○ Research state-specific requirements IFSP reviewed every 6 months and updated once per year IFSPs and IEPs IEPs contain eight components ○ Present levels ○ Measurable annual goals ○ Description of how progress will be measured ○ Description of special education or other services ○ Amount of time per school day the child will receive special education ○ The child’s participation in standardized assessments, including modifications ○ Start date, duration, frequency, location of services ○ Written consent for services Reviewed annually Reevaluated every 3 years Transition to adulthood Writing SOAP Notes Used in medical settings to facilitate communication Elements of a SOAP note ○ Subjective ○ Objective ○ Assessment ○ Plan Reading and writing SOAP notes can be challenging for beginning clinicians Share Assessment Findings Results should be shared with client, caregiver, and others involved in client’s care Information-sharing meeting Online, in person, phone Review written report Use jargon-free language, illustrations, charts, diagrams to clarify and explain Sensitivity to feelings Allow time to process Emphasize client’s strengths Ask questions that allow the client/caregiver to participate End by discussing next steps Share Assessment Findings Sharing Information Electronically Most efficient method Sending Reports via Email PHI and maintaining client privacy is an ethical and legal priority Electronic Medical Records and Electronic Health Records EMRs are digital version of a client’s medical records EHRs are similar to EMRs; Client’s medical records can be shared by professionals across health care organizations HIE allows for secure and timely client-centered care Assessment via Telepractice Service delivery via telecommunication technology Types of telepractice ○ Synchronous telepractice ○ Asynchronous telepractice ○ Hybrid telepractice Benefits ○ Provide care in rural areas ○ Convenient ○ See clients in real-life environments Drawbacks ○ Technological barriers ○ Confidentiality ○ Environmental distratctions Assessment via Telepractice Assessment Considerations Specific to Telepractice Not every client is a good candidate Same expectations for in-person assessment apply to telepractice Many standardized tests not normed for telepractice Various modifications When writing final report, state that assessment was completed via telepractice