Download General Diagnostic Report Shell

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:
Address:
Date of Evaluation:
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.
Revised 5/11/12
**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. You
may 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., xxxx) 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
Mean = xx; Standard Deviation = xx
Revised 5/11/12
Standard Scores
Percentile
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 any non-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 Skills If 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 any non-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.
Revised 5/11/12
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 any non-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:
o Clear statement of diagnosis
o Severity
o Characteristics
o 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.”
Revised 5/11/12
“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:
o Treatment recommendations, including amount and duration
o Recommended treatment areas
o Recommendations for further assessment, if indicated
o Recommendations for related services such as OT evaluation, if indicated
o Recommendations to facilitate functional communication success, such as
educational accommodations or modifications, etc.
o 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
Graduate Student Clinician
Revised 5/11/12
____________________________
Supervisor Name, Degree, CCC-SLP
Speech-Language Pathologist
Clinical Supervisor