Review Speech Pathology Assessment
Purpose of Review:
Reassessment of communication skills following a 6-month block of intervention focusing on expressive language development in a 5-year-old child diagnosed with Developmental Language Disorder.
Progress Toward Goals:
Significant progress observed in expanding vocabulary and sentence length. Family reports a noticeable improvement in '[Patient Name]'s ability to form 3-4 word sentences spontaneously at home. School reports indicate increased participation in group activities and improved ability to convey needs to teachers and peers. "[Patient Name]" successfully identified 8/10 common objects and actions during structured play.
Current Communication Status:
Receptive language skills are within age-appropriate expectations for single-step commands. Expressive language has shown marked improvement, with an increase in mean length of utterance (MLU) from 2.5 to 3.8 morphemes. Speech clarity has improved, with a reduction in phonological errors, specifically fronting and stopping. "[Patient Name]" is now consistently using gestures to supplement verbal communication when explaining complex ideas. Interaction with peers has become more frequent and sustained, with less reliance on adult prompting.
Swallowing Status (if applicable):
Not applicable. This review focuses solely on communication development.
Therapy Completed to Date:
Eighteen sessions of individual language stimulation therapy delivered weekly at the clinic, focusing on narrative skills, vocabulary expansion, and sentence formulation. Caregiver education was provided weekly on strategies for promoting language development in the home environment, including recasting and parallel talk. Compliance with home activities, such as reading daily and engaging in descriptive play, has been excellent, as reported by the mother.
Updated Goals:
New goals established collaboratively with the parents include: "[Patient Name]" will independently initiate a conversation with a peer at crèche on 3 out of 5 observed occasions, and "[Patient Name]" will produce grammatically correct sentences of 4-5 words to describe a past event, using appropriate verb tenses, in 80% of opportunities.
Recommendations / Next Steps:
Continuation of weekly individual therapy sessions for another 12-week block to target narrative skills and social communication. Referral to audiology for a routine hearing check to rule out any underlying auditory issues. Recommendations provided to the crèche teacher for incorporating visual schedules and choice boards to support communication during transitions and group activities.
"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."
Purpose of Review:
[state reason for follow-up e.g. reassessment, ongoing monitoring, review of intervention progress, or discharge planning following completion of sessions at a public clinic, community health centre, or private practice]
(Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Progress Toward Goals:
[summarise client progress in relation to previously established communication or swallowing goals. Include references to school participation, family observations, or improvement in daily function if noted]
(Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Current Communication Status:
[update on receptive/expressive language, speech clarity, functional communication, code-switching between languages, use of gestures or visual supports, and interaction with peers or caregivers]
(Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Swallowing Status (if applicable):
[comment on swallowing safety (e.g. oral vs PEG feeding), food textures tolerated (per SA IDDSI framework), use of compensatory strategies, and caregiver feedback on mealtime safety]
(Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Therapy Completed to Date:
[outline sessions attended at the clinic or via community/home-based services. Include type of interventions used (e.g. language stimulation, oral motor therapy), use of caregiver education, and compliance with home activities]
(Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Updated Goals:
[include any newly established goals, collaboratively developed with the client or family. Reflect culturally appropriate and functional outcomes, such as communicating basic needs at crèche or improving speech clarity for school participation]
(Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Recommendations / Next Steps:
[comment on continuation or modification of therapy programme, referral to allied services (e.g. audiology, dietetics, OT), recommendations for school-based support, or preparation for discharge to community services]
(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 placeholder completely.)