In today’s academic and health care climate, accurate and clear documentation has never been more important. Diagnostic Report Writing in Speech-Language Pathology seeks to demystify and simplify the challenges many students and clinicians face while learning to write speech and language evaluations by combining the science and art of assessment with an effective presentation.
Dr. Steven H. Blaustein uses his more than 50 years of experience as a clinician, consultant, and professor to logically guide the reader through the necessary steps involved in the documentation of a speech and language evaluation. From discussing the initial reason for the referral and case history to the final summary, impressions, and recommendations, each step of the writing process is clearly explained.
Topics included in Diagnostic Report Writing in Speech-Language Pathology:
- Speech sound production
- Oral peripheral examinations
- Issues of law, fairness, and ethics
- Critical information for the approval of services and third-party reimbursement
- Common report writing errors to avoid
- Images and tables to illustrate the process of documenting a speech and language evaluation
There is no one-size-fits-all template for documenting an evaluation. Diagnostic Report Writing in Speech-Language Pathology: A Guide to Effective Communication provides the reader with the skills and knowledge necessary to compile an effective professional report that meets the needs of patients, clients, students, and outside stakeholders.
About the Author
Foreword by Gary S. Mayerson, JD
Chapter 1 Diagnostic Report Writing: Initial Thoughts
Chapter 2 Some Notes on Report Writing Style
Chapter 3 Ethics, Fairness, and Law: An Important Trio
Chapter 4 A Reason for the Reason for Referral and a Case for the Case History
Chapter 5 Behavioral Observation: That Is All You Need to Do
Chapter 6 Speech Sound Production: Writing Clearly About Clearly Speaking
Chapter 7 The Oral Peripheral Examination: A Mouthful of Description Will Suffice
Chapter 8 Choosing the Language for Documenting Language
Chapter 9 Language Is Not Always Standard
Chapter 10 You Need to Know More: Specific Documentation by Setting
Chapter 11 Summary and Impressions: Time to Put It All Together
Chapter 12 Recommendations and Referrals: What It’s All About, So Write It Right
Chapter 13 One More Read: 10 Common Errors in Report Writing to Avoid
About the Editors
Steven H. Blaustein, PhD, CCC-SLP, BCS-CL, holds a Certificate of Clinical Competence in Speech-Language Pathology from the American Speech-Language-Hearing Association (ASHA) and is a Board-Certified Specialist in Child Language with more than 50 years of clinical experience. He holds a doctorate degree in Speech and Hearing Sciences from the Graduate Center of the City University of New York.
Dr. Blaustein’s experience includes 18 years at Mount Sinai Hospital in New York where, in addition to providing clinical services for children and adult inpatients and outpatients, Dr. Blaustein spent 4 years as the coordinator and consulting speech-language pathologist to the Cleft Palate and Craniofacial Disorders Center. He directed a hospital-based program for speech and language disorders and has consulted for a variety of programs and agencies. This work included completing thousands of evaluations for the New York State Early Intervention Program and numerous preschool programs serving New York City Committees on Preschool Special Education. He continues to advocate for individuals with communication disorders and routinely conducts independent speech and language evaluations and presents his findings and opinions at impartial hearings and has testified in court. Dr. Blaustein has presented numerous continuing education workshops, seminars, and lectures on various speech- and language-related topics throughout the United States, including frequent presentations at annual conventions of the ASHA. Dr. Blaustein has served on advisory boards for social skills programs and therapeutic schools for children with communication disorders. He has had papers published in Neurology and Journal of Communication Disorders and contributed a chapter to ALS: A Guide to Patient Care. Dr. Blaustein reviews assessment instruments and textbooks related to language disorders for various publishers. His current interests are in the areas of evaluation and diagnosis of communication disorders, autism, social pragmatic language disorders, speech sound production, Early Intervention, and interprofessional education.
Dr. Blaustein has served as Adjunct Clinical Professor at a number of colleges and universities and is currently a full-time Associate Professor at the Touro University School of Health Sciences Graduate Program in Speech-Language Pathology. He continues to maintain a private practice specializing in the assessment of toddlers and children.