Writing clinical reports will be closely guided by your clinical supervisors in your first year. Writing reports that are meaningful and make sense to both professional and client audiences is a complex process. There are many right ways and few things that are just not okay. The information below will get you started!
You will complete an Initial Report and a Progress Report each clinic term for each client. These reports include the following information:
Client Information
Background Information
Assessment Results
Impressions
Additional Information
Term Objectives/Results of Term Objectives
Recommendations (Progress Report Only)
* Information included in the Initial and Progress Report may vary depending on the clinic assignment. See your clinical supervisor with any questions.
In order to report standardized test results in a consistent manner, it is imperative to include specific data. Use the following guidelines when scoring tests and generating written reports:
Use the full name of test with acronym in parentheses the first time you mention it in the report
The acronym may be used in the rest of the report.
Purpose of the test; what the test assesses specifically
Raw scores
Standard scores, percentiles
Severity rating, if appropriate
Do not report age equivalents
Statement as to whether the scores fall within the average range or how far from average they are
Comparison to previous testing, if appropriate and available
Description of overall performance; strengths and weaknesses demonstrated
Recommendations if appropriate
All clinic reports need to be signed by you and the clinical supervisor, with degree and title included. Ask your clinic supervisor for their credentials.
Name/Degree
Graduate Student Clinician
Name/Degree/CCC-SLP
Clinic Supervisor
Before submitting a report to your supervisor, proofread for the following areas:
GRAMMAR: The correctness of sentence structure, verb conjugation, subject/verb agreement, and tense.
PUNCTUATION: The use of apostrophes, colons, semicolons, dashes, quotation marks and commas.
TYPING: Consistency in spacing, margins, and paragraph format.
SPELLING: Correct spelling of words and use of approved abbreviations.
CLARITY: The text is easily understood with examples to support client’s behavior, and/or test findings. Specific terminology is defined as appropriate.
COMPLETENESS: All pertinent information is included in the semester treatment plan, final semester report, or diagnostic report. Case history, and impressions and recommendation sections are complete (i.e. the reason for referral, disorder, severity level, prognostic statement, specific recommendations).
PARALLEL VERB TENSES: There is consistent use of the same verb tense throughout the report as appropriate.
ACCURACY: All identifying information, direct quotes, client history, and performance information is accurate.
COHERENCE: The report follows logically from one section to another. The body of the report supports the “Impressions and Recommendations” sections.
REDUNDANCY: Excessive repetition of the client’s name, a specific type of sentence structure (e.g., prepositional phrases) or information is avoided.
NONESSENTIAL INFORMATION: All information from the file or observation that is not pertinent or important is omitted from the report.
FILE ORDER: Consent/waiver and release forms, report, and pertinent forms (e.g., diagnostic protocols) are filed in correct order in the client’s folder.
Don’t use the word around, Do use the word approximately.
Don’t: GB’s intelligibility is judged to be around 80% in a known context.
Do: GB’s intelligibility is judged to be approximately 80% in a known context by the clinician
Always include the degree of the supervising clinician and other clinicians, professionals mentioned in the report.
Don’t: GB was referred by Jill Smith.
Do: GB was referred by Jill Smith, MA, CCC-SLP
Always refer to the measured skill rather then the child.
Don’t: He was found to be within the typical range.
Do: His expressive language was found to be within the typical range according to this measure
Always write out the full name of the clinic before abbreviating.
Don’t: GB receives intervention twice week for 50 minutes at the OSR Clinic
Do: GB receives intervention twice week for 50 minutes at the Oregon Scottish Rite Speech and Speech and Language Clinic (OSR Clinic)
Always write out the full name of the test before abbreviating.
Don’t: GB was administered the GFTA on October 9, 2009.
Do: GB was administered the Goldman Fristoe Test of Articulation (GFTA) on October 9, 2009.
Always use exact percentages when possible.
Don’t: According to probe data collected on October 9, 2009, GB was able to produce s blends in over 80% of opportunities
Do: According to probe data collected on October 9, 2009, GB produced /s/ blends in 85% of opportunities
Always state who reported the information in the report.
Don’t: GB’s motor development occurred within the expected time frames.
Do: Per GB’s mother, his motor development occurred within the expected time frames
Always state what IS reported.
Don’t: Mrs. S doesn’t report that there is an increase in dysfluencies at certain times of the day, during certain activities, or emotional states.
Do: Mrs S. reports that there is no increase in dysfluencies at certain times of the day, during certain activities, or emotional states.
Always give an example of what Mean Length of Utterance means.
E.g. According to a language sample collected on October, 10, 2010, john demonstrates a mean length of utterance of 3.1. mean length of utterance is a measure of the number of words per utterance as well as the morphemes used in that utterance (e.g. past tense ed, and plural s)
Describe what you see demonstrated in assessment
Don’t: John has a severe language disorder
Do: According to an assessment conducted on October 10, 2010, John demonstrates a severe language disorder
Always describe behaviors demonstrated rather than make a conclusion about the abilities of a client.
Don’t: Fred demonstrated the ability (or Fred was able to use) to use 3 word phrases
Do: Fred demonstrated the use of 3 word phrases in multiple opportunities throughout the session.
Include information about a client’s interests in your documentation of their behavior
Don’t: Fred loves to play with blocks and is a big fan of Star Wars
Do: Fred demonstrated coordinating eye contact with one word requests and appeared to enjoy playing with blocks with the clinician as demonstrated by smiles and frequent requests for more play.