Writing clinical reports is an important skill for any speech and language pathologist. The writing needs to be both professional yet written in a family friendly way. It is important to consider your audience when you are writing and to provide enough information that the report paints an accurate picture of the student you are writing about.
I will put in some examples of progress report sections that have been well written here to aid you in the set up of your report. The names are not real to protect the privacy of the client but they have been written by fellow clinicians.
I used a variety of progress reports so the below examples are many different children. It is more the set up of the progress report and what is an example of the information that I wanted you to see.
Background: This section provides background information and a brief statement about the services for the current semester.
Alexa Jones is a 7:3-year-old diagnosed with expressive and receptive language delays. Ann Poor, M.A., CCC-SLP of the King School Department referred Alexa to the Best Speech and Hearing Clinic in May 2013. She has been receiving services at the Best clinic since May 2013.
The focus of her most recent intervention includes improving her expressive oral language and listening comprehension, including vocabulary, irregular past tense verbs, and identifying the elements of narrative grammar.
Alexa is in the first grade. She attends King Elementary School where she received speech therapy twice a week, according to parent report.
Treatment began Feb. 15, 2016 ,and ended April 25, 2016, for the spring semester. Alexa attended 7/10 once weekly 50-minute sessions. The focus of Alexa’s intervention this semester was listening comprehension of narrative grammar, expressive language, vocabulary,and syntax.
Initial Assessment: The purpose of this section is to report initial testing that helped to drive what you decided to work on this semester.
Jackie was probed informally on her ability to produce regular past tense verbs. The clinician presented three picture cards depicting actions in the past, present and future. Jackie was asked to produce the verb depicted in the scene (i.e. fold) when given verbal cues. (i.e. Yesterday she folded the towels; Right now she is folding the towels; Tomorrow she will fold the towels). Jackie correctly produced 70% of past tense verbs. Based on Jackie’s performance and recommendations from the previous clinician, syntax, specifically past tense verbs were targeted as a goal in treatment.
Treatment Approach This section is used to describe how you addressed the client’s goals. It is important for you to focus on evidence-based approaches for addressing goals.
Grace’s general treatment approach involved components from the previous semester with activities based on the philosophy of the SCERTS Model. The SCERTS Model (Prizant, Wetherby, Rubin & Laurent, 2007) is an evidenced-based approach and multidisciplinary framework that addresses the core challenges face by individuals with autism. The approach focuses on building competence in social communication, emotional regulation, and transactional supports as the highest priority and is applicable to individuals with a wide range of abilities. Activities were structured for Grace to enhance her learning with scaffolding levels of support (i.e. visuals, schedule). She had frequent opportunities to initiate communication, respond to communication bids, maintain conversational topics, work together as a team, and make choices.
Formal and informal assessments were used to determine Mary’s baseline level of performance and establish appropriate goal areas for the semester. Assessment focused on articulation and pragmatic language. An articulation screener was administered as a means to guide further assessment in more specific areas. The results of the screener determined that Mary’s only sound in error was /r/, which indicated a need for a standardized /r/ assessment.
The Entire World of R Advanced Screening:
Based on Mary’s previous goals and recommendations from the Spring 2016 semester in addition to her difficulty with the production of /r/, The Entire World of R-Advanced Screening was re-administered to determine the best /r/ to target this semester. The Entire World of R- Advanced Screening assesses a total of 32 types of /r/ (Ristuccia, 2010). According the test authors, /r/ productions falling between the 50% to 80% accuracy are appropriate targets for therapy. MP was most successful on the /r/ blends in which her tongue was in an elevated position due to the surrounding sound. Her errors on other /r/ contexts consisted of distortions as oppose to substitutions or omissions. The /kr/ context was selected as an appropriate target based on the following results in addition to the results of previous screenings and her previous treatment goals.
|/r/ placement||Single word||phrase||sentence||Total % correct|
An informal assessment of Mary’s conversation skills was completed to determine her use of conversational turns, comments/follow-up questions and eye contact. Questions were written on Jenga blocks. Each player answered the questions on the blocks they pulled and discussed their answer with the other player. This activity was designed to both provide an opportunity for Mary to use her conversation skills while also building clinician/client rapport.
Mary’s conversational turns throughout the activity were limited to short 1-2 sentences. She asked little to no follow up questions regarding the clinician’s response and rarely made comments regarding the topic of discussion. Mary also made no eye contact throughout the activity. These observations indicate that Mary struggled with some pragmatic skills, specifically those needed to effectively share and gain information from a conversational partner.
M = Objective met.
IP = Objective in progress
NI = Objective not introduced
|Goal I: Charlie will maintain his overall intelligibility by accurately producing target consonant and vowel sounds.|
Charlie will produce /th/ in all positions at the sentence level given visual cues with 90% accuracy across three consecutive sessions.
|Met with 100% accuracy on 2/24/16.|
Charlie will produce “oo” vowel (e.g., “cook”) within single-syllable words given visual, auditory, and tactile cues with 80% accuracy across two sessions.
– Charlie is presented with a target and a prolongation visual.
– While elongating the vowel sound in each word he pushed a lego along the visual, providing a tactile and visual support.
|Met with 100% accuracy on 2/24/16.|
Home Program: This section is used to describe the family’s (parents, spouses, caregivers, etc.) contributions including their implementation of a home program, their perspectives on the client’s progress this semester, and their future goals.
Home Program Example 1
Paige’s home program consisted of sending her home with a copy of her /IRE/ medial word list highlighting the words from her session that day. Paige was asked to practice articulating each word ten times per day while using self-discrimination to determine “old way” versus “new way.” She was also provided with visual support of a diagram of the articulators to practice /IRE/ in isolation if having difficulty determining the accurate placement of her tongue
Home Program Example 2
Heather’s home program consisted of sending her home with a copy of her /IRE/ medial word list highlighting the words from her session that day. HJ was asked to practice articulating each word ten times per day while using self-discrimination to determine “old way” versus “new way.” She was also provided with visual support of a diagram of the articulators to practice /IRE/ in isolation if having difficulty determining the accurate placement of her tongue.
End of the semester assessments: This section is used for testing or sampling of speech/language skills conducted at the end of the semester to measure generalization of skills.
Grace completed the Goldmann Fristoe Test of Articulation-2 (GFTA-2) on July 13, 2015, to assess her articulation after receiving a semester of treatment. JF completed the Sounds-In-Words subtest and received a standard score of 97.
The results from the GFTA-2 are as follows:
Current Status and Impressions: This section goes beyond the objective information to discuss implications relative to the client’s functioning.
Ann is diagnosed with Autism Spectrum Disorder.
Ann enjoyed participating in conversations with the clinician at the beginning to each session. She showed improvement over the semester in her development of appropriate topics for conversation and readily initiated conversation with the clinician. Ann provided appropriate comments and follow-up questions to maintain and extend conversation while using the “Comment and Question” board to visually prompt and motivate her to continue the conversation. At the end of the semester, Ann was able to consistently develop appropriate topics for conversation. Ann continues to exhibit trouble knowing when to switch topics and how to provide smooth topic transitions during the conversations.
Ann exhibited interest in learning how to write descriptive paragraphs but tended to become frustrated when the clinician asked her to revise her first ideas for supporting information and conclusions. Ann readily developed information related to her topic sentence and enjoyed describing the provided pictures. She began working on sequencing her brainstormed information for her descriptive paragraph. During the editing process, it became apparent that Ann was having difficulty developing a concluding sentence that restated her topic sentence. Ann, therefore, practiced writing concluding sentences before refocusing on sequencing ideas. At the end of the semester, Ann was able to develop appropriate topic sentences, supporting information, and concluding sentences for descriptive paragraphs. Ann continues to show difficulty in sequencing her supportive information.
Ann read The Scarecrow’s Hat, Caps for Sale, and Dear Juno this semester and worked hard on developing her narrative skills. Ann easily identified the descriptive and active sequences of the books; she also identified the reactive sequence of the stories with minimal with some prompting from the clinician. Ann demonstrated mastery of the new vocabulary words she learned in the Text Talk® program. She enjoyed doing vocabulary Bingo activities for homework particularly the more creative tasks such as drawing pictures of the vocabulary words. At the end of the semester, Ann demonstrated competence in finding the reactive sequence in the stories she read and in using the new vocabulary words she had learned.
Ann was a delight to work with this semester. She came to each session happy and willing to work hard on the therapy activities. Ann’s parents were very supportive of her work and progress during therapy. They made sure she completed all of her homework assignments and provided help when Ann had trouble. Ann’s made good progress this semester and will benefit from continued help in developing her conversational, writing, and reading comprehension skills.
Kathy has significant receptive, expressive and pragmatic language difficulties secondary to her diagnosis of Autism Spectrum disorder. She thrives on routine and structure and needs careful consideration of the set up of the therapy environment, including a schedule of therapy activities, visual supports for new information and clear behavioral expectations. It should be noted that there are differences in Kathy’s focus and attention depending on the day and/or activity. There are some days or activities that require more structure or sensory input to enable her to sustain attention. It should be noted that Kathy is now able to read simple sentences so these may be used in place of pictures for visual supports.
Kathy did extremely well with her articulation goal and this is no longer a difficulty.
She also was able to spontaneously use pragmatic skills that were taught in previous semesters (e.g greetings). Kathy’s expressive language increased significantly as evidenced by the lengthier more complex answers to questions however she still needs continued work on pragmatic language.
Based on Kathy’s consistent hard work, regular attendance to therapy, and positive attitude coupled with very supportive and attentive family indicates a positive prognosis for further improvement.
- It is recommended that Connor continue to receive services twice a week for one-hour sessions.
- Future goals for intervention include:
- Continue using Moving Across Syllable: Training Articulatory Sound Sequences or another evidence-based program to treat CAS
- Continue using visual/tactile cues for support
- Administer an assessment such as the Kaufman Speech Praxis Test (KSPT) to determine other phonemes for intervention
- Assess maintenance of /l/ in the initial position at the word level, progress to phrase level
- Progress to /l/ in the medial and final positions at the word level