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1. What are the 6 documents used for clinical documentation?: 1. Assessment
Reports
2. Treatment Plans
3. Lesson Plans
4. SOAP Notes
5. DATA Logs
6. Progress Reports
2. is the written log of what has occurred with your client.-
: Documentation
- It is impossible to keep track of all that has been said and done to your client within
your head.
- It is impossible to know when treatment it is working, and when it is not....
- Everything that is done regarding your client, should be documented on some form,
determined by the supervision SLP, to ensure for adequate record keeping.
- Some of the documentation is completed by your supervisor only, and some maybe
completed by both of you...
3. - Written after testing
- Provides background information
- Strengths & areas of need
- Written by SLP only
- Written after an initial evaluation is administered.
- It determines if there is a presence of a disorder or not.
- It identifies the clients strength and areas of need.
- Evaluations are typically administered by an SLP. However, in some cases,
the SLP may train a SLPA to administer an assessment battery. When this
occurs the SLPA is expected to present the assessment to the client, and mark
if the responses are correct or incorrect.
- The SLP is responsible to interpret client's performance.
- This means that the SLP is responsible for reviewing the results of an
assessment to determine if there is a presence of disordered communication.
- , is the document that results from the evaluation, must be
written by the SLP.: Assessment Reports
4. What are you look for on assessment reports?: 1) Identifying background
information
2) Current levels of performance
3) Difficulties presented
4) Behaviors
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5) Treatment Plans
- In some cases, the assessment report is your first glimpse at your client's specific
needs.
- When reviewing an assessment report, you want to get a feel for this client.
- Look for information that tells you about the clients identifying and background
information.
- Basic info such as name/age, language, who client lives with, any medical con-
cerns, current diagnosis, other services provided, level of education, etc. (This will
give you and idea of the level you want begin your engagement with your client.)
- This will begin to paint a picture in your mind of your client and will give you the
initial pieces of how your client should present.
- Also consider the level of current performance. What can the client do? Is he/she
verbal, can he/she produce sentences, can he/she hold a conversation etc. (This will
give you an idea of the level you want to begin you engagement with your client.)
- You will also want to understand what type of difficulties your client presents with.
- This will also give you an overview of your client's communication needs.
- Seeing the client's defects will give you an idea of the severity of their communica-
tion disorder, as well as an idea of how your client will look.
You also want to look for description of behaviors and temperament of your client. Is
this client easy going with compliant behavior that will require very little reinforcers,
or does the client have challenging behaviors that will require you to plan specific
behavior management strategies.
- And finally, some reports may have some direction of treatment plan. This is usually
found in the recommendations section and it is a general overview of what the client
needs to work on. It may or may not have specific goals written, but it should give
some direction in which way to go.
5. Standard Scores
- Average: 90 - 110
- Low Average: 80-89 (Mild)
- Borderline: 70-79 (Moderate)
- Deficient: 69 & Below (Severe)
Standard Deviations
- 1.5 SD below the mean
- SS: 77.5
Percentile Ranks
- 6th Percentile Rank
- Typically don't see client's above average (11 and up)
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