Report


 * Report Writing ** [[image:paperwork.jpg width="137" height="147" align="right" caption="(5:j)"]]

Now comes the fun part! After completing a clinical or instrumental assessment a report of the findings must be completed (Cichero & Murdoch, 2006). This report can be in a format such as the example in the link below.The format will vary depending on the clinician and facility however the the sections will remain similar. This report includes the following sections: assessment, summary of case history and current medical status, recommendations, intervention summary and plan and would be added to the patients file. The recommendations should be discussed with the patients care team which are in the team approach section (Murray, 1999).



A narrative style report is often written for the patient or family. (Murray, 1999). This report could include the following sections recommended by Murray (1999): introductory statement, results, impressions, recommendations, and patient education. The introductory statement includes the purpose of the examination, patient's complaints, consistencies and volumes trialed.

The **results** section is the "just facts" section describing each stage of the swallow that was assessed. The **impressions** section is the "how and why" description by the clinician as well as a severity rating. It may also include the reactions to compensation and intervention. The **recommendations** section should be written as suggestions and not as orders to the patient. Ultimately it is the patient or the families decision to follow recommendations. This is in accordance with the the ICF model which shows how negative changes in any component of a person such as the category of Body Functions and Structures or Contextual Factors can affect the persons quality of life which would be reduced Activities and Participation (Washington, 2007). The ICF model recommends that SLT's assess functioning in all components as intervention should also focus on all three components. The ICF model will be discussed further in the intervention section following.

Intervention