Able/unable: Do not use these terms to describe what you observed as your report captures only a specific point in time and not what the client is capable of performing under different circumstances/settings. The client either did/did not perform the task as part of the assessment. The terms able and unable are vague and do not accurately describe observations or clinical data. Always write in absolute language (what was observed rather than what was not observed).

Example: “The client was able to recite the days of the week.” can more simply be stated as, “The client independently recited the days of the week” or “The client recited the days of the week with minimal prompting.”

Appear/seem: Do not use these terms to describe the client’s behavior. Instead describe the behaviors you did observe. For example, “The client exhibited grunts, sighs, and a slouched posture during periods of word finding difficulties.”—instead of, “The client seemed frustrated.”

Labeling: In addition to the above, do not label- instead, describe your observations or behaviors.

Quotation marks: Enclose all direct quotations (words, phrases or sentences) within two double quotations marks (“and”). Use single quotation marks (‘and’) to enclose a quotation within a quotation.

In most cases, place the punctuation mark WITHIN the quotation mark, except when followed by a parenthetical reference. Double-check for missing quotation marks at the beginning or the end of quotations. For example: The client’s mother reported that AB is understood by his “buddies” but not by “other people.” AB is reported to “finger feed himself Cheerios” and eats soft food with a spoon.

When a reference citation follows a quotation, the period is placed after the closing parenthesis. For example: According to Soundson, “hearing impairment costs billions of dollars to the nation’s health care system” (1993, p. 9).

Verb tense: Keep verb tense consistent!

Past tense: Always write background/case history information and your observations/outcome data in past tense as you are reporting what already happened.

Present tense: The summary and impressions section of your report should be in the present tense as you are concluding what the client’s present difficulties are. For example, “Mr. X is a 65-year-old male who experienced a stroke. The client currently presents with a moderate expressive and receptive language disorder, characterized by…”

Future tense: The recommendations section of your report as well as your goals should be written in the future tense as you are reporting how you suggest the client will proceed post-evaluation and the long-term goals that will be targeted in treatment.

Omitting articles: Do not omit articles when writing your report. While we want to write in as concise a manner as possible, omitting articles will produce telegraphic writing, and the report should still read as a professional narrative. For example, “The client presented with…” is preferred, as opposed to “Client presented with…”.

Acronyms: When using acronyms, you must always write out the full name and then cite the acronym before using it independently. For example, “New York University (NYU).” You may then proceed to use “NYU” throughout the report as an acronym. In our profession, especially within the context of the evaluation, there are several acronyms that come into play. It cannot be assumed that the reader of our report will know each of these and what they represent. Therefore, the word or term with a citation for its acronym must always be referenced before independent use throughout the report.

Client’s initials: To protect the client’s privacy (and to ensure compliance with HIPAA), do not use the client’s name when writing your report. Use only the client’s first (if a child) or last initial (if an adult, e.g., “Mr. X”) and no other identifying information (such as home address, date of birth, names of relatives). When using the client’s initials, make sure your writing is uniform. Do not write “AB” in one sentence, and then “A.B.” in the following sentence. Keep your writing consistent.

Client criteria: When writing your report, always include the client’s age, sex or gender identity, and disorder, so that your report is comprehensive and the next person who reads it has an understanding of your procedures and the client’s profile.

Diagnostic and treatment codes: Always include ICD-10 codes and/or CPT codes in your heading. In clinical practice, these are necessary for billing and data collection purposes.

Test names: Always write test names and underline them as well. For example, Western Aphasia Battery-Revised (WAB-R)*. Subtests should be italicized.

*This is also another example of acronym citation. Once you write the full test name, the bolded acronym may be used for all future references in the report.

Subject-verb agreement: The subject and the verb should agree in number. The terms that intervene between the noun phrase and the verb do not affect agreement. For example, “Each individual is responsible for their actions” should be “Each individual is responsible for his or her actions” OR “Individuals are responsible for their actions.” Another example is, “These techniques, when used appropriately by a competent clinician, are known to be effective” should be “These techniques…are…”

Pronoun use: When writing your report, do not overuse pronouns, especially in the objective outcome section of your report. When you do use them, make sure the subject is clear before using a pronoun. Keep pronouns to a minimum as to not make your report colloquial or the subject vague.

Topic sentences: Always include a topic sentence at the beginning of every section in your report. The topic sentence summarizes and introduces what your report will include in that section. Do not begin a section with data or a procedure.

Formatting: Always use the NYU Clinic’s report format. It is very important that you keep all sections and their respective headings together. Never hand in a document in which the heading for a section begins on one page, and the section continues on the next page. If this leaves you an odd amount of space on a certain page, that is OK! The information staying together is essential.

Sentence length: Run-on sentences are not considered grammatical. Shorter, complete sentences are preferable.

Colloquialisms: Do NOT write as if you are texting or g-chatting with your friends. Remember that this is a piece of clinical writing often seen by physicians, other paraprofessionals, and concerned caregivers. (You may think this is obvious, but it is easy to slip!!)

Proofreading: Always proofread your work! OR Have a friend proofread your work! Reading your report aloud is a strategy that is helpful in identifying mistakes.

Redundancy: Avoid redundant words or phrases, especially at the beginning of sentences. Use a thesaurus if it will help.

Clinical writing: Write in a concise yet comprehensive manner. Make sure you write everything you need to—in the shortest and clearest way possible—without sacrificing necessary content.

Person-Centered Language: Always use person-centered language (“experienced” instead of “suffered”). Your language should be objective and positive, rather than subjective and negative. Do not refer to the client as “aphasic, autistic, language disordered, stutterer”. Instead, you may state that the client has a “diagnosis of aphasia/autism/language disorder/fluency disorder”. Substitute ‘although’ for ‘but’ in sentences to promote more positive phrasing.

Parameters: Always include all parameters assessed within each section of your evaluation. For example, if you are writing about fluency, you should include the parameters of rate, rhythm, prolongations, and repetitions to discuss your observations and determine whether or not the client’s fluency is within normal limits.

Positive Statements/Skills: Always frame statements in a positive way. Instead of describing what the client did not do and what you did not observe, state what the client did do and what was observed. In addition, always describe the skills you evaluated and observed, instead of describing the tasks you used to elicit the skills being evaluated or observed.

i.e. and e.g.: Please use these appropriately. They are both abbreviations for Latin terms and it is

acceptable to use them with either commas or parentheses: i.e. = “that is”, e.g. = an example that is not finite.

*Remember: Most likely, the evaluation that you write will be handed off to another speech-language pathologist, so it should be comprehensive! The next therapist should be able to read it and know exactly how to proceed.

Do's

• “shows”, “exhibits”, “manifests”, “demonstrates”, “displays” rather than "has a condition"

• “produces” rather than "makes" or "says"

• “increased” or “improved” rather than "got better"

• “was administered” rather than "gave a test"

• “performance was within normal limits” rather than "did really well on a test"

• “stated” or “reported” rather than "said"

Do not omit articles

• DO: “The client presented with…”

• DON’T: “Client presented with…”

Ambiguity

• Be specific when describing client performance

• DO: “The client exhibited semantic paraphasia on 50% of trials during a confrontation naming task.”

• DON’T: “The client has word finding problems.”

• Avoid terms “able/unable” and “appear/seem”

• Write in absolute language and describe observed behaviors and clinical data

• DO: “The client experienced frustration, demonstrated by grunts, sighs, and a slouched posture, during periods of word finding difficulty.”

• DON’T: “The client seemed frustrated.”

Tense errors

• Pay attention to the nature of the section you are writing and use appropriate tense

• Past tense – case history, background information

• Present tense – summary and impressions, current communication status

• Future tense – recommendations, prognosis, goals

• Avoid switching tense within the same section

Writing conventions

• In general, reports are written in passive tense

• Passive: “Mike was observed to use several multiword utterances”

• Active: “Mike said four three-word sentences”

• Do not use contractions or shortened/informal versions of words (e.g., “rehab”)

• Use person-first/patient-centered language

• DO: “person with aphasia”

• DON’T: “aphasic person”

• Use the client's initials to protect privacy (HIPAA compliance)

• Be consistent across report (e.g., don’t use Joe B., JB, J.B., Mr. B. – pick one version)

• May vary depending on setting (e.g., electronic medical records in hospital)