How To Document Treatment Planning (Mahler)

Front 1

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Importance of Documenting

Back 1

a. Treatment of communication disorders must be
planned based on a thorough assessment - tell a
story based on evidence of your assessment
b. Report results in a meaningful way
NB: Your written account of what you did is
legal proof of what you did & what you will be
held responsible for

Front 2

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Writing Treatment Goals (Need…)

Back 2

a. Knowledge of normal development & specific disorder area to Establish hierarchy of difficulty
b. Knowledge of your client's current level of performance to determine starting point and long-term goal

Front 3

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Writing Treatment Goals (Need…)
(Continued)

Back 3

a. Knowledge of writing behavioral objectives (ABCD) so goals are measurable
b. Knowledge of the individual you are treating

Front 4

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Diagnostic Reports

Back 4

a. Paint a verbal picture of a clinical case and
lead the reader through the collection of
pertinent data to a logical diagnostic
conclusion
b. A good diagnostician takes information
from multiple sources (pt, fam, diagnostics,
etc.) and synthesizes it to arrive at a
diagnosis with treatment recommendations.

Front 5

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Organization

Back 5

a. Concept is critical to professional communication!
b. One of the key variables that distinguishes professional from nonprofessional writing (logical and organized)

Front 6

a
Framework for Report Organization

Back 6

a. Identifying information (who is person,
address, age, etc)
b. Background information (medical, social, etc)
c. Biological bases of communication
d. Basic communication processes that are
disordered
e. Diagnostic test results
f. Clinical impressions
g. Summary and recommendations

Front 7

aa
Identifying Information

Back 7

a. Name
b. Date of birth
c. Gender
d. Address
e. Telephone number
f. Best method of contact
NB: Basic demographic information

Front 8

aaa
Background Info

Back 8

a. Case history
b. Prior treatment methods, duration & effectiveness
c. Reason for referral
d. Pt's statement of problem

Front 9

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Case History

Back 9

a. Medical, personal, professional (all of this helps you
to understand the whole person)
b. If you want Tx to be salient (tasks and materials that are meaningful/ purposeful), you need to know the person

Front 10

aaaaa
Reason for Referral

Back 10

a. Ask them even if you know the answer to hear their view on their problem
NB: Adults patients need physician referral

Front 11

b
Biological Bases of Communication

Back 11

a. Oral motor function
b. Auditory acuity (is it acuity prob or lang prob? - might modify tx based on response)
c. Neurological integrity
NB: Establish biological bases by assessing everything else

Front 12

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Basic Communication Processes

Back 12

a. Language
b. Articulation
c. Cognition: Attention, memory, organization, planning, reasoning, problem-solving
d. Voice and Resonance
e. Fluency
NB: Assess or screen in the above areas based on diagnosis (don't waste time assessing all of them if you don't have to) --> rarely is formal testing of all processes indicated

Front 13

bbb
Diagnostic Test Results

Back 13

a. Focus on reason for referral
b. Quantitative data (dx tests are good at this) -
tell you measurements but don't tell you how
to plan tx
c. Qualitative data (behavioral checklist, or take
activity important to individual and assess -
let's do a checkbook if you manage finances
in your house)
• Report in objective terms!

Front 14

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Clinical Impressions

Back 14

a. Interpret test results in the context of the individual’s background and situation to arrive at a diagnosis and prognosis

Front 15

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Summary and Recommendations

Back 15

a. This section of the report is the one most frequently read, so write it as if it's the only thing someone is going to read
b. The evaluation is briefly summarized and
specific recommendations for treatment are clearly described.

Front 16

c
Long-term Goals (LTG)

Back 16

a. Stipulate what the patient/client ultimately wants to achieve - don't write w/ %,
b. Think of it as "why they came to therapy"

Front 17

cc
Short-term Goals (STG)

Back 17

a. Achievement of a communication skill that is
necessary in the hierarchy for achieving the
long-term goal.
b. Breaks ltg into individual goals to achieve
ltg skill set
c. Goals should be specific
d. Usually there are multiple short-term goals in a treatment plan but only one long-term goal
NB: Think of STG as the little things the pt needs to do in order to achieve the LTG

Front 18

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Examples of LTG and STG

Back 18

a. Long-term: “Lane will produce all age-appropriate
phonemes in spontaneous speech to
improve understandability.”
b. Short-term: “Lane will spontaneously produce /t/ in the final position of words while naming picture cards with 90% accuracy.”

Front 19

cccc
Behavioral Objectives

Back 19

a. A statement that describes the intended
target behavior in an observable and
measurable way.
b. The blueprints for how to conduct a treatment session.
c. Pretend a diff clinician has to take over for you and can do tx based on the behavior objectives you've already written

Front 20

ccccc
Writing a Behavioral Objective

Back 20

a. Audience: who is expected to demonstrate the behavior (eg: the client)
b. Behavior: the observable and measurable behavior
c. Condition: the context or condition of
the behavior (eg: single words, connected speech, etc)
d. Degree: the targeted degree of success

Front 21

d
Example of Components of an Objective

Back 21

a. Bill
b. will eat a mechanical soft diet consistency diet with nectar thickened liquids
c. using a chin tuck posture
d. 90% of the time throughout a meal (% high for eating b/c can't choke!)

Front 22

dd
Example of Components of an Objective
(Continued)

Back 22

a. Lee
b. will generate a sequential written list
c. of the steps necessary to do the laundry
d. independently with 90% accuracy

Front 23

ddd
Example of Components of an Objective
(Continued 2)

Back 23

a. Susan
b. will include narrative elements of setting and character
c. by correctly producing a spontaneous story in response to a sequence of pictures
d. on 3/5 presentations during treatment

Front 24

dddd
Treatment Rationale

Back 24

a. “Why do I do what I do in treatment?” - take behavioral objective and then say why you want client to be able to achieve the behavioral objective
b. Rationale is an underlying principle that provides the logic, reasoning and/or basis upon which your treatment tasks are based.
c. The rationale for your treatment may be based on several factors.
NB: School objectives must be linked to the curriculum (eg: vocabulary and concept development or social curriculum)

Front 25

ddddd
Evidence-Based Practice

Back 25

a. Integration of clinical expertise, best current
evidence, and client values
b. The goal of EBP is to provide the highest
quality services available to the people we
serve.
c. Integrate knowledge you learn from studies
( ones you do or ones you read about)

Front 26

e
About University Clinics

Back 26

a. Evaluation process is longer – may be up
to 2-3 hours
b. Reports are longer and more detailed
which is useful for training but not always
necessary in external placements
c. Students are asked to do more as part of
skill training

Front 27

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General Guidelines

Back 27

a. Be concise – wordiness can confuse the reader about your point
b. Use professional terminology - specific about
communicative behavior
c. Be objective –separate fact from opinion (don't ay
they were anxious say the behavior that made you
think they were anxious)
d. Be specific – ambiguous statements don’t contribute
to the results
e. Check spelling and grammar!