Title: Documentation and providing information
1Documentation and providing information
2Providing InformationWritten documentation
3Overview of written documentation
- What is the purpose of the diagnostic report?
(record of clinical encounter) - Who is/are the consumers of the diagnostic
report? (RNs, physicians, family, school,
insurance) - What makes an excellent diagnostic report?
(Informative, scientific, objective,
observations, recommendations concise but
thorough and clear) - What skills are important for excellent
documentation? (knowledge)
4Purpose of documentation (Paul Hasselkus, 2004)
- Support diagnosis and treatment
- Support reimbursement
- Communicate with other practitioners
- Justify clinical decisions
- Document communication among involved parties
- Protect legal interests of the client, service
provider and facility - Serve as evidence in a court of law
- Provide data for quality improvement/research
5Format
- Varies by clinical setting
- Narrative (UNT-SPHS)
- Checklist
- Template / computer based
6Medical Based Practice
- Speed and efficiency are key
- Use of check-lists / templates are the norm
- Move toward electronic records
- Intuitive electronic records becoming more common
- Minimal use of narrative format
- Format consistent with requirements of funding
sources (Medicare/Medicaid) and regulatory
agencies (Joint Commission on the Accreditation
of Healthcare Organizations)
7Problem-Oriented Documentation
- Frequently used in medical settings for
speed/efficiency - Emphasis on documenting problems and developing a
care plan in response to the problem (document
the abnormal) - Vs.
- Documenting overall status
8Diagnosis/ Problem-Specific Templates
- Information is specific to the type of evaluation
- Examples
- Voice evaluation
- Fluency evaluation
- AAC evaluation
- Swallowing evaluation
9Education Based
- More uniform documentation format based on laws
(94-142, IDEA 04, etc.) - IEP is the central document used for documenting
problems, goal areas, recommendations, etc. - The IEP is reviewed/updated annually
- A complete re-evaluation is required every 3 years
10Consumer rights re documentation
- Both HIPAA and IDEA 04 specify consumers rights
to access and give input re records - HIPAA outlines a procedure for a client to
request a change to a medical record. The
provider is allowed ultimate authority regarding
ammendment - Parents must sign an IEP to express agreement and
have due process if necessary
11Characteristics of the Evaluation Report
12Style
- Objective
- Third person
- Formal, no slang
- Precise/specific clear word selection avoid
nebulous words such as good, some trouble
with or problem with Be objective! - Concise
- Informative
- Accurate
- Neat and legible
13Information
- Identifying information
- History
- Statement of the problem
- Evaluation results
- Impressions (diagnostic statement, findings
consistent with - Prognosis, for what? E.g., prognosis for
communication improvement is poorALS (expected
course of the disorder) - Recommendations (referrals, more test, therapy
trajectory, goals)
14Identifying Information
- Name
- Address
- Birthdate / age
- Referral
- Medical diagnosis
- Guardian
15History
- Presenting complaint/problem
- Description/example
- Developmental/medical/educational history
- Psychosocial information (social expectations,
reports of behavior problems, loner, very
outgoing, etc.) - Previous history/treatment
- Goals for the evaluation
- History should be summarized as concisely as
possible
16Example
- Mr. Smith is a 74-year-old retired plumber who
suffered a left-hemisphere stroke on 6-14-09
resulting in dense left hemiparesis, severe
aphasia, and dysphagia. He is currently on a
mechanical soft diet with level III thickened
liquids. He is inconsistently able to
communicate basic needs. His discharge plan is to
return home with his wife and continue
out-patient therapy.
17Evaluation results
- Fill name of test, underlined, with abbreviation
in parenthesis - Preschool Language Scale, 4th
edition (PLS-4) - Brief description of the test Is a
standardized, norm-referenced test use to measure
overall language skills in children ages 2 5
years - Results overall scores/ subtest scores
- Interpretation
18Example CELF
Language Index Skills measured Standard Score
Core Language General language ability 72
19Example interpretation
- The Core Language Score is a measure of a
students overall language ability and is used to
make decision about the presence or absence of a
language disorder since it is obtained from the
subtest that best discriminate typical language
performance from disordered language performance.
Sarahs standard score of 72 places her -1.72
standard deviations from the mean, indicating
that her performance is most like children with a
language disorder.
20Example CELF
Subtest Description Raw Score Meets criterion
Phonological awareness Measures knowledge of the sound structure of the language and the ability to manipulate sounds 12 No
21Example Interpretation Statement
- Phonological awareness is closely linked to
reading and spelling and has been shown as a
valid predictor of a childs ability to learn to
read in multiple studies. Joes failure to meet
criterion indicates that he does not have adquate
phonological skills to support reading achivement
22Observational assessment
Observed skill Usually present (80 or more) Occasionally present (50 or less Not present
Usese visual/written cues X
Requests repetition from teacher X
Verifies/ confirms understanding of assignment X
23Example Interpretation Statement
- Results of observation in Johns classroom
indicate that he does not consistently utilize
strategies to assist him with comprehension of
information in the classroom setting
24Example Dynamic assessment
Phonological Awareness Skills Pre-intervention accuracy Post-intervention accuracy
Syllable blending 35 80
Rhyme detection 60 90
Rhyme production 45 75
Initial phoneme identification 20 60
25Example Dynamic assessment interpretation
- John demonstrated improvement in all phonological
skills covered during a mediated learning
experience where he was provided direct
instruction, indicating good potential for rapid
development of phonological skills with
intervention
26Impression
- Provides a clear, concise summary of the
diagnosis, functional skills and prognosis
27Example of impression
- John presents with a moderately severe specific
langauge impairmemtn (SLI) that continues to
interfere with academic success. Although John
demonstrates good response to speech-language
therapy, it is anticipated he will continue to
need academic supports and modification for the
next 3 years to assure educational success.
28The impression section should
- Specify the disorder
- Specify severity of the disorder
- Document the impact of the disorder on function
- Provide a prognostic statement
29Recommendations
- Documents comprehensive recommendations and
specific recommended action items (not just the
need for therapy!!!) - Should include
- Need for additional assessment / referral
- Need for therapy
- Recommended therapy plan (goals, areas of focus)
- Recommend environmental modifications
- Recommendations for client/family education
30An excellent report
- Is accurate
- Is clear
- Does not contain spelling /grammatical errors
- Is easy to read
- Includes both data and interpretation
- Includes all relevant assessment information
(std. tests, observations, dynamic assessment) - Provides clear impression
- Provides specific, comprehensive recommendations
(NOT JUST ENROLL IN THERAPY!!!)
31Tips for writers
- Consider the situation
- Consider the reader(s)
- READ, READ, and RE-READ
- Use words that clearly and concisely describe
the behavior/ skill/ condition - Be objective interpret a behavior only with
evidence Seemed bored with the activity vs.
Stated that the activity was boring
32Tips for writers (cont.)
- Be careful about making statements that present
the client as not motivated (Did not want to
continue with the activity vs. Required
consistent encouragement and reinforcement
throughout the activity) - Avoid jargon
- Delete unnecessary words, sentences, and phrases
- Use charts, etc. to summarize data, including
informal assessment results
33Whats in the future?
- Increased use of electronic documentation
- Computer assisted documentation / decision-making
- Consumer ownership of medical data
- More information on efficacy and effectiveness of
clinical practices, especially as electronic
documentation increases - Efficacy Existence of a measurable change in a
patient characteristic as a result of treatment
(related to body structures and functions and
activity components in WHO-ICF) - Effectiveness Effects of treatment on a
patients daily life well-being (related to the
participation and context components of
WHO-ICF)
34Providing Information Information-giving
interview, post-assessment interview, the exit
conference
35Clinician Anticipates Some Common Client
Complaints
- Quantity of information
- Too much
- Too little
- Quality of information
- Inaccurate
- Over-accurate
36Information-Giving Interview
- (Pre-interview)
- Opening
- Body
- Closure
37Information-Giving Interview
- (Pre-interview)
- Prepare room
- Compile materials
- List key findings
38Information-Giving Interview
- Opening (pp. 121-124 in SR)
- General orientation statement
- Goals
- Time
- Sufficient info gathered (or not)
- Nature of interaction/cooperation
- (page 122 of SR) Ben was very cooperative and
worked hard during the whole session. I was able
to get a good sample of his speech and how hes
making his speech sounds. I want to take the
next 10 to 15 minutes to share the results with
you.
39Information-Giving Interview
- Body
- Structure Funnel vs. inverted funnel
- When anxious
- When less anxious, or when individual has doubts
about the presence of a communication disorder - Content
- Three to five major points (save rest for later)
- Two-way street See if they have questions
- Realistic picture Positive and negative
- Direct, honest, compassionate
- Sandwich them (dont chunk them)
- Why? What would happen if you did chunk them?
40Information-Giving Interview
- Closure
- Complete 2-way discussion
- Summarize
- Findings
- Conclusions
- Suggestions recommendations
- Ask for questions
- May allow for processing time
- Thanks
- Next steps (future) Offer constructive action
41Information-Giving Interview Body(continued,
suggestions)
- What if there are more than 3-5 points?
- Keep language simple
- No jargon, or if you have to use them, define
them - No test or protocol names
- Watch for signs of misunderstanding, overload, or
resistance - Handling emotional responses
- professional, supportive, matter-of-fact
- express sympathy when appropriate (must be
difficult time for you Im so sorry Ill do
whatever I can to support you) - Q Why would you NOT say I know how you feel
I understand what you are going through
42Approaches in Information-Giving
- Treat all members as conversational equals
- Offer constructive action
- You may be seen as bearer of bad news
- Provide encouragement when possible and
appropriate - Dont expect immediate action on suggestions