Ch 4 - Quiz 2 Flashcards

(38 cards)

1
Q

How to provide clinical findings, conclusions, and recommendations

A
  1. Information giving sessions
  2. Written reports
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2
Q

Information giving sessions characteristics

A

Persons present: clinician, client, caregivers
Conducted in person, over phone, or online
3 parts:
1. Introduction
2. Discussion
3. Conclusion

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3
Q

Components of information giving sessions INTRODUCTION

A

Meeting purpose
Explain structure of meeting, including time needed
Report whether of not adequate information was gathered at AX
If meeting with caregivers, report on client’s behavior at AX

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4
Q

Components of information giving sessions - DISCUSSION

A

Present major findings and conclusions from AX
Do not use jargon
Emphasize major points
Provide written report that summarizes results of AX
Use charts, illustrations, etc to clarify info
Encourage client to ask questions

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5
Q

Components of information giving sessions - CONCLUSION

A

Summarize major results from AX, conclusions and recommendations
Ask if additional questions/comments
Thanks for participation
Describe next steps

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6
Q

What aspects of written reports may differ across clinical settings?

A
  • Format
  • Style
  • Scope
  • Length
  • Degree of detail
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7
Q

Do most AX reports have a similar format?

A

Yes, most AX reports (i.e., diagnostic reports) have a similar format and present the same general information.

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8
Q

What would written assessment reports include?

A
  1. Identifying information
  2. Overview/background/presenting complaint/initial status
  3. Histories
  4. AX information
    (Articulation and phonological processes, language, fluency, voice and resonance, dysphasia)
  5. Orofacial examination
  6. Summary
  7. Recommendations
  8. Clinician’s Name/signature/credentials
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9
Q

Logical progression of report

A

Intro leads to AX findings
AX findings lead to conclusion and recommendations

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10
Q

Services authorized through IDEA

A

IFSPs and IEPs

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11
Q

What are IFSPs and IEPs

A

Plans to meet needs of child
Weaknesses identified
goals written to target weaknesses
Goals written by collaborating team and parent
Written consent required
describes how services will be delivered
how progress will be measured
Outlines disabilities and needs
Describe services
Emphasize importance of family participation

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12
Q

What does IFSP stand for?

A

Individualized Family Service Plan

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13
Q

What age group does the IFSP target for early intervention?

A

Infants and toddlers (birth through age 2 years 11 months)

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14
Q

Who receives early intervention services under the IFSP?

A

Infants & toddlers with disability or developmental delay and their families

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15
Q

What does the IFSP identify regarding a child’s development?

A

Child’s current developmental level

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16
Q

What does the IFSP state regarding service provision?

A

Natural environment where services will be provided

17
Q

True or False: The IFSP includes provisions for families as recipients of services.

18
Q

What does the IFSP identify as necessary for achieving expected outcomes?

A

Early intervention services needed

19
Q

What is the transition plan mentioned in the IFSP?

A

Supports transfer to preschool program/Transfer to IEP at age 3

20
Q

How often is the IFSP reviewed?

A

At least every 6 months

21
Q

Who coordinates the services outlined in the IFSP?

A

County regional center

22
Q

What does IEP stand for?

A

Individualized Education Program

23
Q

What age range does the IEP cover for special education?

A

Aged 3 years to 21 years

24
Q

What is the main purpose of an IEP?

A

To provide special education for children with disabilities

25
What does an IEP identify regarding a child's academic performance?
Child's current level of academic performance
26
What information does an IEP state about service provision?
How much time child will receive services Apart from school
27
Does the IEP include provisions for family involvement?
No provisions for family included
28
What does the IEP identify in terms of services needed?
Special education services needed to achieve goals
29
How long is support provided for IEP
Supports transition to adulthood upon or before reaching 21
30
How often is the IEP reviewed?
At least every 12 months
31
Through which agency are IEP services coordinated?
Local educational agency
32
8 components of IEP
1. Present level of functioning (PLOF) and academic achievement 2. Measurable annual goals 3. How progress will be measured and how frequently progress reports will be provided 4. Description of services child 5. Amount of time per school day will receive services 6. If and how child will participate in standardized assessments, including modification allowed 7. Start date, duration, frequency, and location of services provided 8. Written consent for services from parent/legal guardian
33
When write SOAP notes?
Medical setting to report client info Immediately after being seen Can be used to coordinate care Used during evaluation and treatment phases Part of client’s legal medical records
34
Components of SOAP notes
Subjective Objective Assessment Plan
35
Subjective (SOAP)
Non-measurable Problem from client’s point of view including current complaint Relevant past and recent history Client’s level of concern, degree of cooperation, and overall affect
36
Objective (SOAP)
Meaureable findings Initial diagnostic session: document examination results Treatment sessions: document objective performance measures on treatment tasks
37
Assessment (SOAP)
Interpretation/analysis using sub and ob measures included in previous sections of notes Diagnostic session: write conclusions and recommendations Treatment sessions: write current status in relation to goals Write so other professionals understand session outcomes
38
Plan (SOAP)
Record plan of action/plan of care -list next steps