"What am I reading?"
If you've started speech therapy recently or have been attending for some time, you've likely been given a report that has a lot of information inside. It can be overwhelming to dig through a report, especially if it's your first one. We're here to help you learn what information is included, where to find it, and how to decipher it all.
1. Evaluation Report
The evaluation report is the first step in beginning speech therapy and is usually the first report you will see from your child’s speech and language pathologist (SLP). Evaluation reports usually provide background information, reason for the evaluation, diagnostic and service information, informal and formal testing results, analysis, recommendations, and proposed goals. We’ll explain each section of the report we provide families with here at Speech SF. The information you see on your report could be different depending on where your child receives speech and language therapy.
A.) Background Information
All of the information the SLP or clinic collected through intake paperwork should be included in your initial evaluation report. This could include all identifying information, birth and development history, educational history, previous therapy experience and current caregiver/teacher concerns or the reason for the evaluation.
B.) Diagnostic and service information
An evaluation should include a diagnosis (if determined to have one) and service information. Read more about speech and language diagnoses here. Both the diagnosis and service information should have a code attached to them. For example a diagnosis of “phonological disorder (F80.1)” may be given after completing an evaluation of speech sound production (92522).
C.) Informal testing
Informal testing includes caregiver report, any testing which is not standardized, and observations. Depending on the reason for the evaluation, the SLP could look at the strength, range of motion, and coordination of oral structures. They could also make note of the child’s vocal quality, language skills, fluency skills, play or pragmatic (i.e. social) skills. These results do not carry percentages.
D.) Formal testing
Formal testing is standardized and chosen to fit the unique concerns of each child. Standardized testing measures are used across the world with SLPs and are made for specific age ranges. In your report, you should find the name of the test given, scaled scores and percentile ranks which correlate with your child’s performance on each given test.
E.) Analysis
After each test and their corresponding results are documented, there may be an analysis and/or summary to explain performance.
F.) Recommendations
Based on caregiver input, the SLPs observations, and testing, recommendations will be made. These can include recommended speech therapy dosage, referrals to other professionals (e.g. occupational therapy, physical therapy, audiologist, neurologist, reading specialist), or waiting for more development to occur.
G.) Proposed Goals
If speech therapy is recommended, proposed goals may be listed at the end of the report. These are usually the child’s first speech therapy goals chosen based on the testing, the SLPs observations, caregiver concerns, and if the child was able to produce or get close to producing the therapy target.
2. Progress Report
Progress reports are written by SLPs to record progress in speech and language therapy over the course of a certain time period. These can include a reevaluation, but don’t always. Information documented in a progress report includes minimal background information, diagnostic and service information, summary of progress thus far, progress information on each individual speech goal, proposed new goals and a summary with recommendations. If a reevaluation was administered, you should also find informal and formal testing results with analysis as you did with the initial evaluation.
A.) Background Information (minimal)
Minimal background information is provided in a progress note and often refers readers to the initial evaluation report for any historical information.
B.) Diagnostic and service information
As with the evaluation report, the progress report should include any diagnosis and the services that the SLP provided (usually CPT code 92507, individual speech and language therapy).
C.) Summary of progress
This summary will explain how your child is doing in speech and language therapy. It should highlight any strengths, difficulties, and participation in speech sessions.
D.) Informal and formal testing (only if reevaluating)
E.) Progress
Your child’s progress on their speech goals should be given individually per each unique goal. Usually SLPs will classify the status of the goal (e.g. met, in progress, not yet targeted) and a short explanation of their current skill level, along with any cuing needed.
F.) Proposed new goals (if needed)
As development continues, an SLP will provided updated goals as they become appropriate. You may see new goals that haven’t yet been targeted yet listed here.
G.) Recommendations
Updated recommendations are listed usually at the end of the progress report. These can include continuing speech therapy, changing the dosage, referring for a reevaluation, or referrals to other professionals (e.g. occupational therapy, physical therapy, audiologist, neurologist, reading specialist).
3. Exit Report
Exit reports are given to families to document when a child stops speech and language therapy. A child may exit from speech therapy for many reasons including meeting their speech goals, transferring clinics, moving to another place, or for family reasons. At this point, if the child has been in therapy for an extended period of time, an exit report may be given. Exit reports include much of the same information that is found in progress reports including minimal background information, diagnostic and service information, summary of progress thus far, progress information on each individual speech goal, and a summary with recommendations.
A.) Background Information (minimal)
Minimal background information is provided in an exit note and often refers readers to the initial evaluation report for any historical information.
B.) Diagnostic and service information
As with the evaluation and progress reports, the exit report should include any diagnosis and the services that the SLP provided (usually CPT code 92507, individual speech and language therapy).
C.) Summary of progress
This summary will explain how your child is doing in speech and language therapy. It should highlight any strengths, difficulties, and participation in speech sessions.
D.) Specific progress with each goal
Your child’s progress on their speech goals should be given individually per each unique goal. Usually SLPs will classify the status of the goal (e.g. met, in progress, not yet targeted) and a short explanation of their current skill level, along with any cuing needed.
E.) Recommendations
Updated recommendations are listed usually at the end of the report. These can include continuing speech therapy, changing the dosage, exiting or “graduating” from speech therapy, or referrals to other professionals (e.g. occupational therapy, physical therapy, audiologist, neurologist, reading specialist).
Looking for more?
We provide in-depth evaluations, in-home/school speech therapy, and consultations. Sign up here if you’d like to chat with us. Looking for immediate answers? We have those too! Find answers to our most-frequently asked questions here.