Patient Information Name M. L. Birthdate 128XX Diagnosis by sleepover76

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									                                                                                Patient Information

                                                         Name:            M. L.
                                                         Birthdate:       1/28/XX
                                                         Diagnosis:       Cerebral Palsy (spastic quad), Seizure Disorder
                                                         Program:         School Age
                                                         Residence:       Forman ICF
                                                         Service:         Speech-Language Pathology

TREATMENT CLINIC UPDATE                                                                                Date: 4/28/08

Functional Limitations: M. presents with a severe speech and language disorder. He expresses his feelings, wants, and
needs primarily through vocalizations, word approximations, and some simple phrases. He is able to gain attention,
comment, respond to questions, and direct others verbally; however, due to significant difficulties with articulation and
reduced breath support his intelligibility is often compromised. M. also demonstrates the ability to use augmentative/
alternative communication strategies, such as adapted sign language and his DynaVox.

Treatment:                Frequency: 2x/wk                        Duration: 3 months
Precautions: N/A
Adapted Equipment: DynaVox

                                                    Patient Care Plan

Short Term Treatment Objectives:
1. M. will locate an appropriate message on his DynaVox to maintain a conversation for at least three turns given no
   more than two verbal cues with 70% success over one month.
        Status:   Achieved              Improved             Limited Progress No Progress           D/C
2. M. will request a leisure activity by locating an appropriate activity on his DynaVox given no more than one verbal
   cue with 60% success over one month.
        Status:   Achieved              Improved             Limited Progress No Progress           D/C

Present Status: M. locates an appropriate message on his DynaVox to maintain a conversation for two turns with no verbal
prompting. After two turns, M. changes the topic of conversation to an unrelated topic. Prompts of “weren’t we talking
about ____,” redirect M. to the first topic helping him maintain the flow of conversation. At times, M. intentionally
changes topics or avoids answering questions to escape tasks or to play with his conversational partner. M. has shown
improvement in navigating to the correct page when choosing a leisure activity in his new classroom. When the activity is
highly motivating, such as play practice or functional communication about the weekend, no support is needed for
navigation. If the activities are less motivating then minimal support is given through verbal prompting. If the preferred
leisure activity is not programmed into his DynaVox, M. vocalizes to let his communication partner know and the activity
is programmed when possible.

Recommendations: It is recommended that M. continue to receive speech and language services two times per week.
Therapy should continue to be directed toward the treatment objectives above.


Clinician’s Signature

                     Kristina Hamalainen, BS, Graduate Clinician


                     __________________________________
                     Maria Livermore, MS, CCC-SLP

								
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