How to Write a Case History for Speech Pathology
In order to adequately help a patient receive the treatment they need to communicate more smoothly, there needs to be a case history that allows speech pathologists and other professionals to understand the patient's condition. Often, a patient will not be able to provide this information on their own, so it's very important that you are able to give the doctor the information he or she needs. Once doctor and patient are on the same page, true treatment can begin. Here's how to write a case history for a speech pathologist.
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Instructions
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How to Write a Case History for Speech Pathology
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Provide all of the basic contact information the doctor and his or her staff will need for billing and correspondence purposes. Be sure to include the patient's address, phone number, e-mail address, age/date of birth and anything else you think may be necessary. If the case history is being written for a minor, include the names of the parents and the languages they speak in the home.
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Detail the family history of the patient. This is because some disorders that cause speech problems are genetic. Knowing if autism or specific speech problems run in the family can help the doctor make a diagnosis.
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Describe the symptoms of concern in great detail. Be clear in describing the problems the patient is experiencing. Common problems include stuttering, difficulty pronouncing certain sounds, mumbling/unclear speech and more. Give specific situations in which the problem happens. For example, you might note that, "Her stuttering gets worse when she is under stress or angry."
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Include any unusual details about the patient's birth and gestation. As a result of a number of factors, including oxygen deprivation in the womb, premature babies can grow up with speech problems. If the prospective patient had a seemingly textbook birth, you can just say that.
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Use clear and concise language, but don't be afraid to include details you think may be important. You don't want to fill the clipboard with mundane, everyday details. Anything out-of-the-ordinary, however, is something to include. If the patient happens to have a lot of problems, don't be too shy to ask for more paper or more time.
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Be honest with your responses. Some speech problems can be embarrassing. For example, Tourette's Syndrome can manifest itself by causing the patient to shout improper words or make unpleasant gestures. Remember, the doctor has seen it all before and will not make any judgments.
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