Things not to say
Raw scores should ALWAYS be included in a report.
False- if raw scores carry no meaning, they can be omitted.
True! We should only provide Pass/ Fail information!
The ______ section should include a list of all informal and formal tests administered, which descriptions and interpretation of scores and skills provided.
Results Section
Client gave the examiner a hard time during the evaluation.
What is the trigger word? hard time
Client was initially cooperative with all evaluation tasks, but level of participation decreased as the evaluation tasks increased in difficulty.
ICD-10 codes are not required on diagnostic reports.
False! We must always include ICD-10 codes!
Name three pieces of identifying information:
Name, DOB, Age, Address, Telephone number, insurance policy number, medical record number
The patient was lazy and wouldn't eat their breakfast.
Trigger word: Lazy
Alternative statement:
Goals MUST be included on the diagnostic report.
False, you may write a separate document, such as a Plan of Care to write established goals and to outline the care plan.
When recommending treatment, the ____ and duration of treatment must be indicated.
frequency
The patient couldn't speak English.
Trigger: couldn't speak
Alternative:
Recommendations should address the next steps after an evaluation.
True!
The purpose of the impressions section is to provide a summary or _______ statement(s) about the Patient's skills areas.
diagnostic statement
Patient's self report of their skills is questionable.
Trigger: questionable
An SLP should avoid terms that are not measurable when making prognostic statements!
True!
Name something that should be included in the background/ reason for referral section.
Reason for referral; Presenting complaints; Referring provider; background history (birth, medical, developmental, educational, vocational, social, medications); previous S-L treatment; allergies; history of S-L delays in the family