OUTPATIENT HOSPITAL – PEDIATRIC DIAGNOSTIC NOTE TAKING GUIDE

SPEECH-LANGUAGE EVALUATION

Client: ______Date: ______

Address: ______

Phone Number(s): ______D.O.B.: ______C.A. ______Gender: ______

Parents: ______Diagnosis: ______

Background Information

Reason for Referral

  • Note who referred the client.
  • Explain the reason for referral.
  • Indicate when the problem was first noticed.
  • Give the full names of individuals who accompanied the client to the evaluation and their relationships with the client.
  • List informants (e.g., family member interviewed during the evaluation, teacher contacted by phone).

Birth and Developmental History (if appropriate)

  • Normal, premature, or complicated birth; birth weight
  • Feeding/swallowing difficulties

Achievement of developmental milestones

Medical/Health History

  • General state of health
  • Hearing and vision
  • Serious illnesses, injuries, hospitalizations, medications, allergies
  • Previous evaluations by specialists and diagnoses

Family/Social History

  • Family members: names, gender, ages
  • Household members: names, gender, ages
  • Languages spoken in the home and in other environments to which the client is regularly exposed. Indicate the frequency of use and reported proficiency for each language.
  • Interaction with siblings
  • Attitude of family and friends toward the client’s communication difficulties

Educational/Occupational History (if appropriate)

  • Schools and educational programs attended and currently attending
  • Academic performance
  • Interaction with peers
  • Attitude of peers toward the client’s communication difficulties

Therapeutic History

  • Type and time period of therapy
  • Name and affiliation of provider
  • Goals addressed and progress achieved
  • Attitude of client and significant others toward therapy

Clinical Observations

Describe the client’s general behavior, demeanor, ability to separate from significant other, cooperation, and attention.

Tests Administered/Procedures

●List the complete names of all tests administered and assessment procedures in the order in which they were conducted. Place abbreviations of test names in parentheses.

1.

2.

3.

Audiological Screening

  • Type of sounds presented (e.g., pure tone)
  • Presentation level (dB HL) and frequency (Hz) of sounds
  • Results: pass or fail

Oral-Peripheral Mechanism Examination

  • Oral-peripheral features/abilities examined and findings (e.g., oral-facial symmetry, dentition, bilabial and lingual mobility, velopharyngeal movement, maintenance of air in oral cavity, condition of tongue and palate, diadochokinesis, ability to swallow various consistencies, etc.)

Language Skills

  • Test:
  • Form of response (i.e., picture-pointing):
  • Description of behavior during testing (e.g., attention, request for repetition, delay in responding, eye contact):

Subtests / Standard Score
(mean = ______) / Percentile Rank
(mean = ______) / Interpretation
(Average, Below Average, Above average, etc.)

Language Sample – write 10 spontaneous utterances (if the child is not verbalizing, write down how they are communicating)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

MLU: ______Typical? ______Notes: ______

Speech and Articulation/Phonological Skills

  • Test:
  • Describe intelligibility in various speaking contexts:
  • Speech rate:
  • Describe the results of stimulability assessment (trial therapy):

Test / Standard Score
(mean = ______) / Percentile Rank
(mean = ______) / Interpretation
(Average, Below Average, Above average, etc.)

Voice and Vocal Parameters.

  • Indicate whether the client’s vocal quality, intensity, and resonance were within normal limits for his or her age, gender, and physical stature.

Fluency

  • Test:
  • Describe dysfluencies:
  • Feelings / attitudes of client and significant others:
  • Describe the results of stimulability assessment (trial therapy):

Recommendations

Diagnosis:

Is therapy recommended: Yes or No

Number of weekly sessions:

A. Long-Term Goals

1.

2.

B. Short-Term Goals

1.

2.

3.

4.

5.

Additional notes: