Initial Speech Pathology Assessment

Reason for Referral: [describe the clinical reason for referral to outpatient speech pathology, including referral from a state hospital ward, primary health care clinic, school-based support team, or private GP. Include relevant background such as post-stroke communication difficulties, suspected dysphagia, or speech delay] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Background Information: [outline relevant medical history, primary diagnosis, previous speech therapy (in state or private setting), and any relevant psychosocial or educational context such as school placement, language background, or caregiver support] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Presenting Concerns: [document patient or caregiver concerns related to communication, feeding, swallowing, speech clarity, language development, or voice quality] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Communication: [describe expressive and receptive language (including use of home languages), speech intelligibility, fluency, social use of language (pragmatics), reading/writing abilities where applicable. Note bilingual/multilingual context if relevant] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Cognition / Communication Support Needs: [comment on attention, memory, problem-solving, sequencing, or cognitive-communication challenges. Include mention of AAC tools (e.g. communication books, PECS), visuals or caregiver prompts used] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Voice: [describe vocal quality (e.g. breathy, hoarse), volume, pitch, resonance, and functional voice use, especially for patients referred with suspected vocal cord pathology or following intubation] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Swallowing: [describe any concerns regarding chewing, oral-motor function, coughing during meals, dietary restrictions (e.g. modified diets), risk of aspiration, or safety at mealtimes. Include details from family or nursing staff if applicable] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Assessment Tools Administered: [list any formal or informal assessments used, such as Receptive/Expressive Language Scales, SSA screening tools, bedside swallow assessment, or observational checklists] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Client Goals: [include functional goals identified by the client and/or family, such as improving speech clarity for classroom participation, safe return to oral feeding, or developing expressive vocabulary in isiZulu and English] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Clinical Summary: [summary of assessment findings, including communication strengths, areas of concern, swallowing safety, and the impact of challenges on daily functioning (e.g. school, work, home communication)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Recommendations / Next Steps: [outline proposed therapy goals or session focus (e.g. receptive language therapy, dysphagia rehab), referrals (e.g. ENT, audiology, dietitian), parent/caregiver education provided, and home support strategies suggested. Include any referrals to NGOs, community rehab workers, or state speech therapy clinics for ongoing support.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own plan or recommendations.) "This set of notes has been produced with the assistance of an AI-scribing service. I confirm that verbal consent has been obtained from the patient. I have reviewed the content of notes and confirm that these are a full and accurate record of my clinical assessment." (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the section completely.)