Basic Information

Diagnostic History

Oral Mechanism

Swallow Evaluation

Voice Evaluation

Cough History

Vocal Hygiene

Cognitive Assessment

Outcome Measures

Assessment & Plan

Patient Information

Name:

Date of Birth:

Medical Diagnosis:

SLP Diagnosis:

Referring Physician:

Primary Insurance:

Date of Evaluation:

Onset Date:

Total Time Spent:

Diagnostic History

Diagnostic History:

Additional Information

Hearing:

Vision:

Diet:

Subjective Information

Medical and social history obtained via:

Patient medical history:

Patient surgical history:

Medications:

Social history:

Patient goals for therapy:

Oral Mechanism Description

Standard Description (normal function) Custom Description

Custom Description:

Additional Oral Mechanism Details

Dentition:

Reflexes:

Vocal Quality:

Respiration:

Speech Production:

Swallowing History

Swallowing History and Current Status:

Prior to onset, the patient was on a diet with liquids.

Swallowing and oral motor concerns include:

Evaluation Considerations

Patient's cognitive status/level of alertness:

Patient's position:

Consistencies assessed:

Oral phase Clinical Observations:

Oropharyngeal Trigger:

Clinical Signs of Aspiration:

Laryngeal Elevation:

Other Observations:

Behavioral Observations:

Compensatory strategies/supports utilized:

Voice History

Patient stated voice problem was in onset.

Patient reported symptoms that over time.

They said the voice would as the day goes on.

Patient vocal misuse including coughing, throat clearing, yelling, etc.

The patient described their voice as and rated themselves as talkative compared to average.

Patient also reported themselves as for conversational loudness.

Voice Analysis

Pitch

Pitch was for age and gender.

Pitch Range was for sustained /a/.

Resonant Quality

The patient presented with resonance per clinical perception.

Rate

The patient's speech rate was

Phonation

Patient able to adduct vocal folds.

Maximum phonation time was seconds for sustained /a/.

Respiration

Respiratory support for speech was characterized by

Musculoskeletal tension

Posture

GRBAS Scale

This scale is scored from 0-3 by skilled clinician assessment.
Score: 0-normal, 1-mild, 2-moderate, 3-severe

G: Grade of Hoarseness:

R: Roughness:

B: Breathiness:

A: Asthenia:

S: Strain:

Additional Features

Voice Quality:

Resonance:

Breathing:

Posture:

Range:

Other:

Cough History

The patient described their breathing/coughing as sounding and reported breathing and coughing difficulties which occurred throughout the night.

Onset:

Duration:

Impacted by Stress:

Impacted by voice use:

Description of cough:

Warning before cough:

Triggers for cough:

Position Cold Heat During ingestion of food

Dust/irritants Odor/perfume Deep breath Laughter

Other triggers:

Perception of control of cough (0=no control, 7=full control):

Effectiveness of strategies/treatment:

Vocal Hygiene

Asthma:

Yes No

Treatment type:

Effect on cough:

Post-nasal Drip:

Yes No

Treatment type:

Effect on cough:

Reflux:

Yes No

Treatment type:

Effect on cough:

Hydration (oz daily):

Caffeine (drinks daily):

Alcohol (drinks daily):

Inhaled irritants (frequency):

Symptom Management

Variability of symptoms:

Duration/Frequency of symptoms:

Resolution of symptoms:

Mini-Mental State Examination (MMSE)

Area	Score	Maximum
Orientation to time		5
Orientation to place		5
Registration		3
Attention/calculation		5
Recall		3
Naming		2
Repetition		1
Comprehension		3
Reading		1
Writing		1
Drawing		1
Total		30

Interpretation:

30: Perfect score, no impairment
25-29: Mild cognitive impairment
20-24: Moderate cognitive impairment
10-19: Severe cognitive impairment
0-9: Very severe cognitive impairment

SPEAK OUT! Evaluation

Conversation:

Reading:

Sustained /a/:

and

Stimulability Testing

Conversation:

Reading:

Sustained /a/:

and

Language Assessment

Receptive Language:

Expressive Language:

Outcome Measures

Voice Handicap Index 10:

Cough Severity Index:

Reflux Symptom Index:

ASHA NOMS:

Education

Results and recommendations of this evaluation have been discussed with and understood by the:

Patient Caregiver Family member

Method of education:

Handouts provided Verbal instructions Demonstration given

Home exercise program:

Retention:

Results and recommendations were discussed and understood by family/patient including:

Assessment

Swallow Assessment:

Patient presents with dysphagia characterized by

Voice Assessment:

Patient presents with dysphonia characterized by

Patient will benefit from skilled speech and swallow services secondary to functional impairments due to:

Rehabilitation prognosis is:

Prognosis considerations include:

Diet recommendations:

Swallow Goals

Functional statement:

In order to improve access to ease of oral nutrition, hydration and medication.

Long Term Goals:

Patient will demonstrate improved swallowing function via repeat clinical evaluation, modified barium swallow study, endoscopic evaluation and/or self rating.
Patient will return demonstration of home program per home tracking forms and patient report to ensure carryover of skilled treatment to functional, real world environment in order to reduce dysphagia and improve ease of eating.

Short Term Goals:

Goal 1: Patient will utilize compensatory strategies as outlined by swallow guidelines including:

with assistance of the time.

Goal 2: Patient will return demonstration of thickening liquids to: consistency.

Goal 3: Patient will tolerate:

diet with liquids without clinical signs of aspiration of the time.

Goal 4: Patient will complete 5 sets of 5 with EMST 150 device independently with 90% accuracy across 2 consecutive treatment sessions.

Voice Goals

Functional Statement:

In order to ensure communication of wants and needs in desired daily living, vocational and safety and emergency situations

Long Term goals:

The patient will demonstrate clear vocal quality without evidence of with adequate in conversational speech.

Short term goals:

1. The patient will demonstrate an understanding of and provide rationale for proper vocal hygiene modifications including: increasing humidification/hydration, eliminating/reducing vocal abuses/misuses (speaking excessively, coughing, throat clearing, yelling, using hard glottal phonation), adhering to GERD precautions, avoiding consumption of caffeinated/alcoholic/carbonated beverages as reported by/documented by the patient throughout the day.

2. The patient will understand the effect of laryngeal tension on phonation and independently complete extrinsic laryngeal muscle relaxation exercises daily as reported by patient and demonstrated to the clinician in therapy room.

3. The patient will understand the effect of laryngeal tension and implement adequate breathing techniques to the clinician with 90% accuracy independently.

4. The patient will improve respiratory-phonatory coordination for sustained vowel /a/ to 9 seconds.

5. The patient will increase vocal intensity to 70 dB for exercises and conversational speech as measured by sound pressure level meter.

6. The patient will use specific voicing strategies during the production of stretch and flow, resonant voice, SOVT with 90% accuracy with min cuing.

Plan

Therapy is recommended times per week for minute sessions for an estimated sessions with frequency adjusted per patient progress.

Therapy will focus on the following interventions and strategies:

Additional Recommendations:

Therapy Charges were separate and distinct activities.

SLP Signature:

Speech Language Pathology Evaluation

Patient Information

Diagnostic History

Prior Level of Function

Additional Information

Subjective Information

Oral Mechanism Description

Additional Oral Mechanism Details

Swallowing History

Evaluation Considerations

Voice History

Voice Analysis

Pitch

Resonant Quality

Rate

Phonation

Respiration

Musculoskeletal tension

Posture

GRBAS Scale

Additional Features

Cough History

Triggers for cough:

Vocal Hygiene

Symptom Management

Mini-Mental State Examination (MMSE)

Interpretation:

SPEAK OUT! Evaluation

Stimulability Testing

Language Assessment

Outcome Measures

Education

Assessment

Swallow Goals

Voice Goals

Plan