Documentation and providing information

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Documentation and providing information
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Providing InformationWritten documentation
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Overview of written documentation

• What is the purpose of the diagnostic report?
  (record of clinical encounter)
• Who is/are the consumers of the diagnostic
  report? (RNs, physicians, family, school,
  insurance)
• What makes an excellent diagnostic report?
  (Informative, scientific, objective,
  observations, recommendations concise but
  thorough and clear)
• What skills are important for excellent
  documentation? (knowledge)

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Purpose of documentation (Paul Hasselkus, 2004)

• Support diagnosis and treatment
• Support reimbursement
• Communicate with other practitioners
• Justify clinical decisions
• Document communication among involved parties
• Protect legal interests of the client, service
  provider and facility
• Serve as evidence in a court of law
• Provide data for quality improvement/research

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Format

• Varies by clinical setting
• Narrative (UNT-SPHS)
• Checklist
• Template / computer based

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Medical Based Practice

• Speed and efficiency are key
• Use of check-lists / templates are the norm
• Move toward electronic records
• Intuitive electronic records becoming more common
• Minimal use of narrative format
• Format consistent with requirements of funding
  sources (Medicare/Medicaid) and regulatory
  agencies (Joint Commission on the Accreditation
  of Healthcare Organizations)

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Problem-Oriented Documentation

• Frequently used in medical settings for
  speed/efficiency
• Emphasis on documenting problems and developing a
  care plan in response to the problem (document
  the abnormal)
• Vs.
• Documenting overall status

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Diagnosis/ Problem-Specific Templates

• Information is specific to the type of evaluation
• Examples
• Voice evaluation
• Fluency evaluation
• AAC evaluation
• Swallowing evaluation

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Education Based

• More uniform documentation format based on laws
  (94-142, IDEA 04, etc.)
• IEP is the central document used for documenting
  problems, goal areas, recommendations, etc.
• The IEP is reviewed/updated annually
• A complete re-evaluation is required every 3 years

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Consumer rights re documentation

• Both HIPAA and IDEA 04 specify consumers rights
  to access and give input re records
• HIPAA outlines a procedure for a client to
  request a change to a medical record. The
  provider is allowed ultimate authority regarding
  ammendment
• Parents must sign an IEP to express agreement and
  have due process if necessary

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Characteristics of the Evaluation Report
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Style

• Objective
• Third person
• Formal, no slang
• Precise/specific clear word selection avoid
  nebulous words such as good, some trouble
  with or problem with Be objective!
• Concise
• Informative
• Accurate
• Neat and legible

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Information

• Identifying information
• History
• Statement of the problem
• Evaluation results
• Impressions (diagnostic statement, findings
  consistent with
• Prognosis, for what? E.g., prognosis for
  communication improvement is poorALS (expected
  course of the disorder)
• Recommendations (referrals, more test, therapy
  trajectory, goals)

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Identifying Information

• Name
• Address
• Birthdate / age
• Referral
• Medical diagnosis
• Guardian

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History

• Presenting complaint/problem
• Description/example
• Developmental/medical/educational history
• Psychosocial information (social expectations,
  reports of behavior problems, loner, very
  outgoing, etc.)
• Previous history/treatment
• Goals for the evaluation
• History should be summarized as concisely as
  possible

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Example

• Mr. Smith is a 74-year-old retired plumber who
  suffered a left-hemisphere stroke on 6-14-09
  resulting in dense left hemiparesis, severe
  aphasia, and dysphagia. He is currently on a
  mechanical soft diet with level III thickened
  liquids. He is inconsistently able to
  communicate basic needs. His discharge plan is to
  return home with his wife and continue
  out-patient therapy.

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Evaluation results

• Fill name of test, underlined, with abbreviation
  in parenthesis - Preschool Language Scale, 4th
  edition (PLS-4)
• Brief description of the test Is a
  standardized, norm-referenced test use to measure
  overall language skills in children ages 2 5
  years
• Results overall scores/ subtest scores
• Interpretation

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Example CELF
Language Index Skills measured Standard Score
Core Language General language ability 72
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Example interpretation

• The Core Language Score is a measure of a
  students overall language ability and is used to
  make decision about the presence or absence of a
  language disorder since it is obtained from the
  subtest that best discriminate typical language
  performance from disordered language performance.
  Sarahs standard score of 72 places her -1.72
  standard deviations from the mean, indicating
  that her performance is most like children with a
  language disorder.

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Example CELF
Subtest Description Raw Score Meets criterion
Phonological awareness Measures knowledge of the sound structure of the language and the ability to manipulate sounds 12 No
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Example Interpretation Statement

• Phonological awareness is closely linked to
  reading and spelling and has been shown as a
  valid predictor of a childs ability to learn to
  read in multiple studies. Joes failure to meet
  criterion indicates that he does not have adquate
  phonological skills to support reading achivement

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Observational assessment
Observed skill Usually present (80 or more) Occasionally present (50 or less Not present
Usese visual/written cues X
Requests repetition from teacher X
Verifies/ confirms understanding of assignment X
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Example Interpretation Statement

• Results of observation in Johns classroom
  indicate that he does not consistently utilize
  strategies to assist him with comprehension of
  information in the classroom setting

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Example Dynamic assessment
Phonological Awareness Skills Pre-intervention accuracy Post-intervention accuracy
Syllable blending 35 80
Rhyme detection 60 90
Rhyme production 45 75
Initial phoneme identification 20 60

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Example Dynamic assessment interpretation

• John demonstrated improvement in all phonological
  skills covered during a mediated learning
  experience where he was provided direct
  instruction, indicating good potential for rapid
  development of phonological skills with
  intervention

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Impression

• Provides a clear, concise summary of the
  diagnosis, functional skills and prognosis

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Example of impression

• John presents with a moderately severe specific
  langauge impairmemtn (SLI) that continues to
  interfere with academic success. Although John
  demonstrates good response to speech-language
  therapy, it is anticipated he will continue to
  need academic supports and modification for the
  next 3 years to assure educational success.

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The impression section should

• Specify the disorder
• Specify severity of the disorder
• Document the impact of the disorder on function
• Provide a prognostic statement

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Recommendations

• Documents comprehensive recommendations and
  specific recommended action items (not just the
  need for therapy!!!)
• Should include
• Need for additional assessment / referral
• Need for therapy
• Recommended therapy plan (goals, areas of focus)
• Recommend environmental modifications
• Recommendations for client/family education

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An excellent report

• Is accurate
• Is clear
• Does not contain spelling /grammatical errors
• Is easy to read
• Includes both data and interpretation
• Includes all relevant assessment information
  (std. tests, observations, dynamic assessment)
• Provides clear impression
• Provides specific, comprehensive recommendations
  (NOT JUST ENROLL IN THERAPY!!!)

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Tips for writers

• Consider the situation
• Consider the reader(s)
• READ, READ, and RE-READ
• Use words that clearly and concisely describe
  the behavior/ skill/ condition
• Be objective interpret a behavior only with
  evidence Seemed bored with the activity vs.
  Stated that the activity was boring

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Tips for writers (cont.)

• Be careful about making statements that present
  the client as not motivated (Did not want to
  continue with the activity vs. Required
  consistent encouragement and reinforcement
  throughout the activity)
• Avoid jargon
• Delete unnecessary words, sentences, and phrases
• Use charts, etc. to summarize data, including
  informal assessment results

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Whats in the future?

• Increased use of electronic documentation
• Computer assisted documentation / decision-making
• Consumer ownership of medical data
• More information on efficacy and effectiveness of
  clinical practices, especially as electronic
  documentation increases
• Efficacy Existence of a measurable change in a
  patient characteristic as a result of treatment
  (related to body structures and functions and
  activity components in WHO-ICF)
• Effectiveness Effects of treatment on a
  patients daily life well-being (related to the
  participation and context components of
  WHO-ICF)

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Providing Information Information-giving
interview, post-assessment interview, the exit
conference
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Clinician Anticipates Some Common Client
Complaints

• Quantity of information
• Too much
• Too little
• Quality of information
• Inaccurate
• Over-accurate

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Information-Giving Interview

• (Pre-interview)
• Opening
• Body
• Closure

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Information-Giving Interview

• (Pre-interview)
• Prepare room
• Compile materials
• List key findings

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Information-Giving Interview

• Opening (pp. 121-124 in SR)
• General orientation statement
• Goals
• Time
• Sufficient info gathered (or not)
• Nature of interaction/cooperation
• (page 122 of SR) Ben was very cooperative and
  worked hard during the whole session. I was able
  to get a good sample of his speech and how hes
  making his speech sounds. I want to take the
  next 10 to 15 minutes to share the results with
  you.

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Information-Giving Interview

• Body
• Structure Funnel vs. inverted funnel
• When anxious
• When less anxious, or when individual has doubts
  about the presence of a communication disorder
• Content
• Three to five major points (save rest for later)
• Two-way street See if they have questions
• Realistic picture Positive and negative
• Direct, honest, compassionate
• Sandwich them (dont chunk them)
• Why? What would happen if you did chunk them?

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Information-Giving Interview

• Closure
• Complete 2-way discussion
• Summarize
• Findings
• Conclusions
• Suggestions recommendations
• Ask for questions
• May allow for processing time
• Thanks
• Next steps (future) Offer constructive action

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Information-Giving Interview Body(continued,
suggestions)

• What if there are more than 3-5 points?
• Keep language simple
• No jargon, or if you have to use them, define
  them
• No test or protocol names
• Watch for signs of misunderstanding, overload, or
  resistance
• Handling emotional responses
• professional, supportive, matter-of-fact
• express sympathy when appropriate (must be
  difficult time for you Im so sorry Ill do
  whatever I can to support you)
• Q Why would you NOT say I know how you feel
  I understand what you are going through

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Approaches in Information-Giving

• Treat all members as conversational equals
• Offer constructive action
• You may be seen as bearer of bad news
• Provide encouragement when possible and
  appropriate
• Dont expect immediate action on suggestions