CAALMS Oral Case Reporting Templates & Sample Scripts

Goals and Competencies Master professional communication and reporting skills to facilitate participation in medical rounds meetings Further develop rational clinical decision making skills

Development of Skills Clinical Decision Making Reporting “Clinical knowing” Reporting “Saying what you know”

Types of Reporting Case Introduction Medical diagnosis (i.e. etiology) Treatment diagnosis Client/caregiver’s presenting concern Previous history treatment Treatment goal Client Progress/Update Goal/Target Approach Measurement

Initial Case Introduction Medical diagnosis (i.e. etiology) Treatment diagnosis Client/caregiver’s presenting concern Previous history of treatment Current outcome goal of therapy including Goal Approach Desired Outcome

Initial Case Presentation Example CLAL is a 75-year-old man who presents with aphasia, including deficits in expressive language, motor speech, reading, and spelling following a cerebral infarction 10 months ago. CLAL’s primary concerns are his intelligibility, his reading deficits, impacting his ability to read aloud to his wife, and his spelling, which impacts his ability to communicate via text messaging. CLAL received speech-language services from Peace Health, targeting language and speech deficits. Following formal evaluation, CLAL received 6 hours of treatment at the HEDCO Speech Language Hearing Center during Summer 2016. Current goals for therapy include improving reading fluency through Multiple Oral Rereading, improving spelling of functional words through ACT and TCART, and education regarding supported communication strategies to improve communication with his wife. Treatment progress of reading fluency will be measured in session by recording the rate and accuracy of his reading of passages at his reading level. Progress of spelling treatment is being measured using spelling probes of targeted words.

Examples and Non-examples Mrs. Smith is a 73 year-old female, 6-months post left hemisphere CVA who presents with right hemiparesis and moderate non-fluent aphasia. Mrs. Smith’s primary concern is her difficulty communicating wants and needs to her caregiver and initiating conversation with her grandchildren. Mr. Jones experienced a severe traumatic brain injury resulting from an assault in May 2008. What’s missing? Neuropsych testing suggests deficits in sustained attention, speed of processing and new learning. So what?

Initial Case Report Components Medical diagnosis (i.e. etiology) Treatment diagnosis Client/caregiver’s presenting concern Previous history of SLP Current outcome goal of therapy including Goal Approach Desired Outcome

Potential Questions Can you give a brief explanation of that treatment? Can you describe that test/measure? Why did you use X measure instead of Y measure ? How are you measuring impact on daily life?

Update Script Include Initial case components This term we are focusing on (goal/target) through (approach). Progress is being measured by (treatment measures) and (outcome measures). Results suggest (outcome). The plan is to…. .

Update Report Example This term we are focusing on. Increasing clients ability to read single words and sentences in order to gain information from written words in the environment ( eg. signs, lists) and regain pleasure from reading materials. Treatment progress is being measured by an increase in accuracy and rate in reading as well as increased ratings on a goal attainment scale and reports of increased reading during everyday activities. of B or higher, and self-report of improved focus while doing homework. Results from our last session showed steady improvement in rate and accuracy. Outcome measures show an increase in reading ability with a rating of +1 on his goal attainment scale, indicating he is able to read multiple words in sentences. The plan is to continue with treading therapy through Multiple Oral Rereading.

Final Report This term we focused on (goal/target) through (approach). Progress was measured by (treatment measures) and (outcome measures). Results suggested (outcome). The plan is to…. .

Final Report Example This term we focused on improving attention, working memory and recall of new information through direct process training (APT) and metacognitive strategy training targeting study skills. Treatment progress was measured by an increase in accuracy and decrease in response time on APT exercises and level of cueing required for study agenda generation. Impact progress has been measured by an increase in performance on the PASAT, an improved completion rate of classroom assignments/tests at a grade of B or higher, and self-report of improved focus while doing homework. Since this was M’s 7th week of APT exercises, the PASAT was re-administered and showed a 2 standard deviation improvement from the start of the term. Results from our last session showed an 90% homework completion rate with grade B or higher. This is M’s 3rd week at this level. M consistently reports a focus level of 4, and increase from 2 at the start of the term. However, M reports he often feels pressure to stop studying to complete home chores. He states he starts and stops chores, losing track of what’s been done, and that this is an area he would like to improve. As M’s LTG targeting study skills has been met, the plan is to discontinue APT exercises and study strategy training. M would like to start a new LTG related to completing home tasks which will be targeted via goal management training.