UNIVERSITY OF WASHINGTON

Speech and Hearing Clinic

Articulation and Language Unit

Final Case Summary

Date

File #:
Date Started – Date Ended
Name:
# individual sessions of 50 minutes each
DOB:
Clinician:	Suzi Clinician, B.S.
Parents:
Supervisor:	Sparky Supervisor, M.S., CCC-SLP
Address:
Disposition:	Continue/Discontinue Therapy
Phone:	( )

BACKGROUND

Identifying Information

Client X, currently age ____ years, was seen for his/her first (second, etc.) quarter of treatment at the University of Washington Speech and Hearing Clinic (UWSPHC) due to articulation delay; phonological delay/disorder; receptive/expressive language delay/disorder; expressive language delay…. (include the following only if appropriate) secondary to a diagnosis of ….

Brief History Update

If this is a returning client who has had a full evaluation through our clinic and a complete history documented in that previous report, only include updated information here. Include especially that information that has direct bearing on your treatment (e.g., hearing status, medications, changes in diagnosis, additional treatment through other sources, updated IEPS, changes in educational status/program).

If this is a new client who has not had a complete history documented in a previous UWSPHC report, then you must include that here. Headings to include:

Identifying information

Referral Source and Chief Concerns

Dates and locations of previous evaluations

Medical/Birth History

Developmental History

Social/Educational History

Previous Treatment

Statement of Treatment Focus

This section explains the focus which is based on previously collect information (collected through previous assessments or other treatment program).

Make sure you consider all areas of communication (see checklist) but focus your discussion on the areas identified as problematic. Here are some POSSIBLE sentence starters.

Previous assessments have revealed problems in the following areas….

Previous treatment has focused on the following targets….

In this section I want to know historically what has been targeted in treatment and the type of progress that has been made. I also want to know specifically what was worked on the previous quarter and the client’s level of performance.

Recommendations from the previous quarter at the UWSPHC include…

Based on previous treatment and/or assessment the following assessment and program focuses on….

_________________ QUARTER 200_ ASSESSMENT

Include

Assessment procedures used and why

If new standardized tests, why

Probes – why those in particular

Other, and why (questionnaires, observations in new setting)

Results of assessments

Specific data

Relate to previous data (make it make sense for the reader)

Interpretation of results in terms of treatment planning.

If you have recommendations from last quarter, your assessment should definitely look at those areas. If your child is new you will probably do a general assessment of communicative behaviors (specific to the presenting problems of the child). Your general assessment and/or previous quarter’s recommendations should lead to the selection of your treatment targets. Once you have selected your treatment targets you need to take baseline data (rates of behaviors in the absence of treatment).

Baselines should be reliable (must be measured repeatedly – across 2 sessions if possible) and they should sample the target behaviors adequately. So standardized tests are not acceptable baseline measures – they do not sample behaviors enough. You will have to design baseline probes that provide an adequate number of trials to establish that a behavior is stable. Giving two (2) opportunities is not enough. Giving three (3) may be – depending on the behavior. Giving ten (10) or more opportunities is the best. Usually, baselines use materials or contexts that are NOT used for treatment so that you are able to better measure generalization. In addition, no instructional feedback is given (although praise for participation can be offered). You generally will use your baseline measure materials to do mid- and final- quarter measures.

Hearing

Only include if we have no information on a normal hearing screening/evaluation

Speech/Articulation

tests administered and results

Test Name

Subtest	Standard Score*	%ile	Interpretation
* “average” = 85 – 115 (although check on this – it varies with tests!)

Identification and analysis of sound errors

Error Patterns

Error	Example	Age Sound Typically Mastered or Age Phonological Pattern Extinguished
/(/ for /s/ substitution	“thumb” instead of “some”	8 years
/ð/ for /z/ substitution	“thoo” instead of “zoo”	8 years

Things to talk about – use headings as appropriate to organize the information

did results of test correspond to speech sound errors observed in conversation. If no, why not?

intelligibility (percentage, rating scale)

Consistency of sound errors

Patterns of sound errors

error types

severity of errors

phonological processes

Stimulability

Rate, prosody, intonation, inflection, etc.

Related Factors

Structural/Functional Evaluation

Treatment Targets and Baseline Measures

Here you can explicitly specify the targets you will work on and present data to demonstrate the client’s current level of performance (2 data points if possible) with regards to your treatment targets. If you want, you can present data within paragraphs above or within a tabular format in this explicit section if that is appropriate. This supervisor (Sargent) enjoys tables and finds them easy to read. Examples:

/s/	/z/

Word position	BL 1	BL 2	BL 3
Word position	BL 1	BL 2	BL 3
Initial	0%	0%	0%
Initial	0%	0%	0%
Medial	0%	0%	0%
Medial	0%	0%	0%
Final	0%	0%	0%
Final	0%	0%	0%
/s, z/ Conversation	0%	0%	0%

MANAGEMENT

The following program was established for therapy.

Long Term Functional Goal:

For any behavioral objectives you write you MUST have assessment/probe data in the assessment section to match it. Otherwise your reader has no idea why you chose what you chose and/or the reader has no idea the client’s baseline performance.

Behavioral Objective 1: These should be written using the behavioral objective worksheet.

Procedure:

Progress: Objective met on (date)/unmet. If not met, discuss what level the client is at (i.e., prompts and cues necessary to elicit the behavior.

Generalization Data:

Behavioral Objective 2:

Procedure:

Progress:

Generalization Data:

Behavioral Objective 3:

Procedure:

Progress:

Generalization Data:

Long Term Functional Goal:

Behavioral Objective 4:

Procedure:

Progress:

Generalization Data:

Other Data

Additional generalization data (new settings, new word positions, related linguistic forms, from words to conversation, etc.)

Other assessments done after the initial assessment, whether standardized or non standardized

Why

Results

ADDITIONAL INFORMATION

What behavioral strategies worked

Homework

Motivation/cooperation etc.

SUMMARY AND IMPRESSIONS

Brief statement about progress.

Do not present information in the summary that was not introduced previously in the body of the report.

RECOMMENDATIONS

Continue/Discontinue treatment

General focus and targets

Any necessary changes

Outside evaluations or referrals

Recommendations for family

_______________________	________________________

Suzi Clinician, B.A.	Sparky Supervisor, M.S., CCC-SLP

Graduate Clinician	Clinical Supervisor

Cc: Parent Name

Parent Address

Parent Address

LASTNAME, Firstname- Page 4
File#

UNIVERSITY OF WASHINGTON

Sargent

2005-10-25