Format Instructions

Format Instructions

Follow this format when completing diagnostic reports. Sequence the areas of assessment (language, articulation, voice, fluency, hearing, etc.) according to concern – biggest concern to be addressed first.

******Note: Some Evaluations may focus specifically on one of the areas of communication (for example voice or fluency). In this instance, other areas may be commented on generally based on observational screening only, and the specific evaluation area may be expanded. The clinical supervisor will provide guidance and direction regarding the report format in those instances.

First page should be on letterhead, so leave space for letterhead.

UNT Speech and Hearing Center Evaluation Report

Name:Date of Evaluation:

Address:

Parents: (if minor)

Birthdate:

Age:Referred by: (if a reference is not listed on the case history, remove this heading)

Name of school: (if school-age)

History

Client’s name , a __ year, __ month old male/female was evaluated at the University of North Texas Speech and Hearing Center on (date). Person, usually parent accompanied client’s name to the evaluation and served as the informant. Client/informant stated his/her main concern was state what he/she said or look at case history for information.

**Add relevant case history information obtained from the case history report and during the evaluation, which may include:

-Reason for referral/statement of the problem

-Medical or developmental history, including current medical status/medications

-Psychosocial and educational background

-Description of functional communication breakdown

-Previous evaluations/treatment and outcome

-Client/caregivers goals for evaluation

-Previous vision or hearing evaluation. If not evaluated make statement of no concerns by parent.

**These do not have to be documented in this specific order. This section should also include any other salient information obtained during the case history interview. Youmay want sub-sections here for specific information. These may include Developmental History, Psychosocial History. Sub-sections should be in italics.

Evaluation Results

Include specifics for the evaluation. (Names of tests should be in italics)

**For example, A hearing screening, oral peripheral examination, language sample (mention all non-standardized assessments used) and a battery of standardized tests consisting of (list the standardized test used) were all used to gather information for an effective and thorough assessment of client’s name’s speech and language skills. During the assessment, XX (add a general statement regarding the client’s overall participation in the assessment and the clinician’s opinion of the validity/reliability of the assessment results). **For example, client’s cooperation, attention, did they need to be re-directed?Did information need to be repeated? How did this affect the evaluation and results?

**Evaluation results should include the following major areas of communication. If an area was not assessed, it should be reported in history as area of no concern.

Language

The (state the name of the test typed in italics) was administered to assess XX’s ______.

**Describe the test (e.g., The CELF Preschool is an individually administered standardized test designed to measure a child’s strengths and weaknesses in language.

This information can be the same information you provide the parent prior to the evaluation.

On this standardized test, a mean of xx with a standard deviation of xx is considered to be within normal limits. Scores that fall within one standard deviation of the mean (i.e., xx-xx) are considered to be within normal limits.(make this relevant to the test given)

The following results were obtained:

**Include a chart with results and statistical data

For example:

Subtests Administered / Standard Scores / Percentile

Mean = xx; Standard Deviation = xx

Provide an interpretation of the data. For example “Test results indicatethat ____is performing above/at/below expectation compared to age-matched peers”. Provide any specific deficit patterns that are observed. Also, provide any significant observations noted during testing.

Include anynon-standardized assessment data such as language or narrative sample, observational assessment, non-standardized criterion referenced assessment, portfolio assessment, and dynamic assessment results. This should include all input from team members.

If a conversational speech and language sample was collected- this section is where you include the “language” interpretation and the “Artic/Phonology” section is where you include the “artic” interpretation of the sample.

Include information regarding Pragmatics/Functional Communication Skills. If there is a specific concern in this area, make a separate section using the heading of Pragmatics/Functional Communication Skills. You do not need a separate section for Pragmatics unless there is a specific concern in this area.

Include information regarding Cognitive/Developmental SkillsIf there is a specific concern in this area, make a separate section using the heading of Cognitive/Developmental Skills. You do not need a separate section for cognitive unless there is a specific concern in this area.

**including attention, developmental play skills, new learning, memory, executive skills, as appropriate to the patient. If child has any behaviors that interfere with the testing, make a statement regarding affect on results.

Articulation/Phonology

**Articulation skills, including observation or standardized assessment results, error patterns, intelligibility and stimulability. Make a statement regarding overall intelligibility and where breakdown occurs (phoneme level, word level, sentence level, conversation)A chart of error patterns can be very helpful here.

**. Include anynon-standardized assessment data such as language or conversation sample, observational assessment, non-standardized criterion referenced assessment, portfolio assessment, and dynamic assessment results. This should include all input from team members.

Oral-Facial Examination

Example: An oral-facial examination was completed and XX’s oral structures and function were judged to be adequate for speech production. If not, give specific details of how it varies and if this impacts speech production.

Hearing

(If Audiologist competed the screening, state that including audiologists name and credentials)

XX’s hearing was screened at __ dB at the frequencies of 1000, 2000, and 4000 Hz in each ear. Screening of middle ear function was completed through imittance testing. State the results. Example: XX passed immitance testing and pure tone screening bilaterally. Or, XX passed the screening the right/left ear but failed in the right/left ear. An audiological evaluation is//is not recommended.

Voice/Fluency

XX’s voice and fluency were observed throughout the assessment and judged to be within the normal limits for his/her age and gender.

Include anynon-standardized assessment data such as conversation sample, observational assessment, non-standardized criterion referenced assessment, portfolio assessment, and dynamic assessment results. This should include all input from team members.

Augmentative/Alternative Communication Strategies(if indicated)

Summary/Recommendations

This section should include:

- diagnostic statements that summarizes the evaluation findings. This should be at least paragraph length. This information should include:

• Clear statement of diagnosis
• Severity
• Characteristics
• Description of how problem may related to functional communication skills, development, and/or academic function.

Examples:

-John presents with a mild developmental phonological disorder characterized by….

-Jane presents with a moderately severe developmental language delay characterized by …..

-

Include a prognostic statement documenting the expected course of the disorder. Also, prognosis for functional communication success may be included if appropriate. Example: Prognosis for describe type of improvement you are targeting is considered ______.

Examples: “Prognosis for improvement in functional communication is considered good.”

“Prognosis for improvement in developmental language skills is good; however residual language deficits may necessitate support/modifications for academic success.

- Recommendations should include the following:

• Treatment recommendations, including amount and duration
• Recommended treatment areas
• Recommendations for further assessment, if indicated
• Recommendations for related services such as OT evaluation, if indicated
• Recommendations to facilitate functional communication success, such as educational accommodations or modifications, etc.
• Recommendations for strategies to encourage successful communication in the home and community

A statement indicating that the client/caregivers were educated regarding the evaluation results, and the understanding and agreement with recommendations. If a follow-up plan is formulated during the evaluation (i.e. the client will begin therapy at the Center), this should be documented as well. It was a pleasure working with ____. Please do not hesitate to contact (supervisor name) at (phone number) with any further questions.

______

Student Clinician Name, Degree Supervisor Name, Degree, CCC-SLP

Graduate Student Clinician Speech-Language Pathologist

Clinical Supervisor

Revised 5/11/12