Reporting Assessment Findings
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| information giving sessions | typically shorter and less formal than the intake interview. usually consists of an introduction, a discussion of findings, and conclusion
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| introduction | state the purpose of the session, explain the structure of the session, state whether sufficient data were obtained, and if reporting to caregivers, a brief statement about the client's behavior.
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| discussion | lengthiest phase of the session. provide a written report and discuss major findings and conclusions. emphasize major points, use jargon free lang., when appropriate use illustrations, graphs, or diagrams to help explain and clarify
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| conclusion | thank the client for participating, ask if they have any questions or comments. provide a summary of major findings/conclusions, recommendations, and describe the next steps that will need to be taken.
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| Individualized family service plan (IFSP) | early intervention services provided to infants and toddlers w/ disability or developmental delay and their families. reviewed every 6 months and updated at least once per year. revisions are made depending on growth and progress towards stated goals.
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| Individualized education program (IEP) | special ed. services for school age children w/ a disability. describes services and education goals that meet individuals needs. reviewed annually. every 3 years, child is reevaluated to see if they still qualify for services.
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| SOAP notes | used in medical settings for reporting client info and facilitating comm. among professionals who also are involved w/ the client. written immediately after working w/ client.
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| subjective | contains non-measurable and historical info. summarize problem from client/caregivers POV. include current complaint and relevant history and info about clients level of concern, degree of cooperation, and overall affect.
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| objective | contains measurable findings. for an initial diagnostic session, document the examination findings. for a treatment session, document objective performance measures on treatment tasks.
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| assessment | synthesis of the info in the subjective and objective sections. for a diagnostic session, write conclusions and recommendations. for a treatment session, record the clients current status in relation to their goals. write so other professionals understand
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| plan | record your plan of action
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