Documente Academic
Documente Profesional
Documente Cultură
Jason Custer
October 9, 2018
positive and effective career. The reports that are written daily are used in numerous different
contexts and need to be presented as professional writing. The famous words that I’ve heard in
many jobs, “If you didn’t document it, you didn’t do it” (Goldfarb and Serpanos, 2014). This
explains just how important not only documenting is, but also being able to do it effectively.
Burris and Willis described Speech Pathologists as one of the most respected in the field of
helping others (2017). Because of this, you want your writing to reflect that. According to
Stein-Rubin and Fabus, diagnostic reports, seen daily, are a crucial part of the profession (2012).
First of all, when considering who the audience of your reports will be, Stein-Rubin and
Fabus discussed the importance of clinicians, and other professionals that may interact with your
client (2012). It’s important that if the client were to get transferred to another professional, that
they would be able to pick up right where you left off and understand exactly which diagnosis
you were working with. With other professionals in mind, it’s important to note that a report you
send over may be the only contact you have with that other clinician (Roth and Worthington,
2005). In order to hold a strong reputation, it will start with strong writing skills. Others may
determine who you are as a clinician based on your ability to effectively communicate and
document. In addition to other professionals, it’s important to remember that family members or
patients may also read any reports that are made. Because of this, some of the technical
language may not be well understood. When discussing terms that may not be familiar to all,
descriptions should also be added to abbreviations. For example, if talking about ASHA, others
might now know that this stands for the American Speech-Language-Hearing Association
While diagnostic reports are one of the most common in the field, Speech Pathologists
also need to be fluent in writing reports, treatment plans and progress notes (Burris and Willis,
2017). In a general report you will typically see background information on the client, case
history, health history, developmental milestones, and education (Stein-Rubin and Fabus, 2012).
Burris and Willis discussed that in Speech Pathologists writings, there should be respect,
(2017). “Careful study must be given to language usage, report composition and form, and the
use of an appropriate writing style” (Middleton, et al., 1992). You must be proper and non-
biased when talking about a client. Also, many times this documentation needs to be turned in
for insurance purposes, so it is very important that everything is correct. Because of this, the
client is trusting that you possess the skills necessary to create the proper paperwork.
Finally, it’s important to remember that the information in a diagnostic report contains
your impression of the client over a certain amount of time, not the client’s overall
communication ability (Middleton, et al., 1992). Once all of a client’s information is gathered
into a diagnostic report, it is then used to determine a treatment plan that will best fit. Treatment
plans are often made by not just the Speech Pathologist, but also many other resources in that
client’s life such as teachers, parents and friends. Anyone that can give insight into what types
of issues the client may be dealing with become an important part of the history. When dealing
with therapy, it is very important to track a client’s progress, so it can be determined whether the
you are in. Although some may use is more than others, in the case of a Speech Pathologist,
your job may depend on it. If you can’t accurately form the background of a client and track all
professionals.
Works Cited
Pathology: How to Write, Talk, and Act Like a Clinician. San Diego, CA: Plural
Publishing.
Middleton, G., Pannbacker, M., Vekovius, G., Sanders, K., & Puett, V. (1992). Report Writing
Roth, F.P. & Worthington, C.K. (2005). Treatment Resource Manual for Speech-Language
Stein-Rubin, C., & Fabus, R. L. (2012). A Guide to Clinical Assessment and Professional Report