Augmentative and Alternative Communication Evaluation Report (Speech-Generating Device)

Report Type: Augmentative and Alternative Communication Evaluation Report (Speech-Generating Device)

Patient Name: [Patient full name]

Date of Birth: [DOB]

MRN/ID: [Medical record number or unique identifier]

Evaluation Date: [Evaluation date]

Report Date: [Report date]

Setting: [Outpatient clinic / Inpatient acute / Inpatient rehab / Skilled nursing facility / Home / School / Other]

Referring Provider: [Name, credentials, role]

Evaluating Clinician: [SLP name, credentials, state license number, NPI, facility/department, address, phone, secure email]

Funding Context: [Payer type and authorization pathway] (If unknown, state: "Funding source not yet determined; report written to support medical necessity and clinical implementation.")

Referral Question

[Reason for referral and primary communication participation problems, including quoted patient/caregiver goals when available] (2–5 sentences. If referral question was not specified, state that evaluation was performed to determine AAC system features needed to meet daily communication needs.)

Evaluation Context and Data Sources

• Encounter format: [in-person / telepractice] (If telepractice, note platform and any limitations affecting assessment or device trials.)
• Participants present: [Names and roles of patient, caregivers, interpreter, providers, ATP/vendor, others]
• Data sources:
  • Record review: [Records reviewed and dates] (If unavailable, state what is needed at follow-up.)
  • Interviews: [Who was interviewed and focus areas]
  • Direct observation: [Context and key observations]
  • Standardized/criterion-referenced measures: [Test names, dates, scores, adaptations, interpretation]
  • Dynamic assessment and device trials: [Brief list of what was trialed]

Case History Relevant to AAC/SGD

• Medical diagnosis/etiology/severity/course: [Primary diagnosis, etiology, severity, anticipated course: stable / progressive / fluctuating] (Attribute to records.)
• Motor/neuromuscular status affecting access: [Posture, reach, fine motor, endurance, involuntary movements, motor planning]
• Vision status and functional impact: [Acuity, visual fields, oculomotor control, contrast/glare sensitivity, implications for symbol size and access]
• Hearing status and functional impact: [Hearing thresholds, amplification use, implications for synthesized output]
• Cognitive-communication profile: [Attention, memory, executive function, learning considerations for device use]
• Languages and cultural-linguistic considerations: [Preferred language(s), dialect, interpreter needs, bilingual output needs]
• Primary environments and partners: [Home, medical, school/work, community settings; typical partners and roles]
• Key communication activities: [High-priority tasks and situations driving AAC needs]
• Prior AAC history: [Systems tried, what worked, what did not, reasons for abandonment]
• Prognosis notes: [Factors supporting prognosis] (If unclear, state that prognosis will be monitored.)

Current Communication Profile

• Speech/voice: [Intelligibility in quiet/noise, consistency, speech rate, vocal loudness/quality, breakdown conditions]
• Receptive language/comprehension: [Following directions, answering questions, complex discourse, supports needed]
• Expressive language: [Vocabulary, grammar, sentence formulation, narrative, word-finding, novel message generation]
• Pragmatics and repair strategies: [Initiation, turn-taking, topic maintenance, repair strategies used and effectiveness]
• Literacy and spelling: [Letter knowledge, decoding, spelling, reading comprehension relevant to text-based AAC]
• Cognition for AAC operations: [Attention, problem-solving, memory for navigation, learning rate]
• Behavioral/sensory tolerance: [Device tolerance, visual/auditory sensitivity, seating tolerance]
• Motivation/self-advocacy: [Engagement, persistence, ability to request help]
• Healthcare communication: [Ability to communicate pain, symptoms, needs, decisions]
• Standardized/criterion measures: [Scores and functional interpretation] (Include only if administered.)
• Areas not assessed: [Domain, reason, and plan to complete] (Include only if applicable.)

Daily Communication Needs Analysis

• Communication partners: [Familiar, unfamiliar, medical, professional, peers, caregivers]
• Environments: [Home, medical, work/school, community, telecommunication] (If evaluation context was limited, note constraints.)
• Communication functions: [Request, refuse, social closeness, information exchange, narrative, self-advocacy, emergency communication]
• Message types/complexity: [Routine phrases vs generative language, vocabulary breadth, technical/medical content]
• Modes required: [Face-to-face speech output, phone, telehealth, text/email, alerts to caregivers]
• Priority outcomes: [Independence, speed, accuracy, fatigue management, portability, durability]

Assessment of Non-SGD Communication Options

(REQUIRED SECTION: Must include explicit findings and conclusion supporting insufficiency of non-SGD methods.)

• Natural speech: [Effectiveness for basic vs complex messages, reliability across environments, fatigue effects, need for repetition, impact with unfamiliar partners]
• Gesture/body language: [Consistency, ambiguity, partner interpretation burden, environmental constraints]
• Manual sign: [Motor feasibility, partner sign knowledge, symbol transparency, generalization]
• Writing/typing without speech output: [Speed, legibility, literacy demands, inability to communicate with listeners who cannot see text, phone/remote barriers]
• Partner-assisted scanning: [Partner availability, speed, accuracy, privacy, independence level]
• Low-tech boards/books: [Vocabulary limitations, navigation load, visibility, rate limitations, dependence on partner pointing/reading]

Conclusion: [Clear statement why non-SGD methods are insufficient to meet daily communication needs, citing specific observed barriers such as rate, reliability, independence, safety, remote communication access, and complex message generation]

Sensory-Motor and Positioning Assessment

• Seating/positioning: [Wheelchair/seating system, head support, trunk support, table or mount needs]
• Upper extremity function/endurance: [Range, accuracy, tremor, activation force, sustained use tolerance]
• Head control/range: [Stability, range for head mouse/head pointing]
• Eye control/visual stamina: [Fixation, saccades, tracking, blink, tolerance for eye gaze calibration and duration]
• Auditory access to output: [Ability to hear synthesized speech in typical environments, need for amplified output]
• Environmental modifications: [Glare, lighting, noise, space for mount]
• OT/PT input: [Recommendations obtained or referrals needed for positioning/mounting]

Access Method Evaluation

(Document each method trialed with setup, settings, and outcomes. If a method was not trialed, state why. Recommend primary and secondary/backup access methods.)

• Direct selection (touch/stylus/keyguard/alternative touch):
  • Setup: [Posture, device position, mount, keyguard, target size, spacing]
  • Settings: [Touch accommodations, acceptance time, repeat, filtering]
  • Performance: [Accuracy, error patterns, speed, independence, fatigue]
  • Interpretation: [Clinical rationale for suitability or limitations]
• Eye gaze:
  • Setup: [Calibration success, seating, distance, lighting]
  • Settings: [Dwell time, activation method, calibration points]
  • Performance: [Accuracy, latency, endurance, need for re-calibration, independence]
  • Interpretation: [Suitability and constraints]
• Switch scanning (single/dual/multiple):
  • Setup: [Switch type and location, mounting, activation force]
  • Settings: [Scan pattern, scan speed, acceptance time, auditory prompts]
  • Performance: [Selection accuracy, time to target, fatigue, cognitive load]
  • Interpretation: [Suitability and constraints]
• Head tracking/joystick/mouse emulation:
  • Setup: [Device, mounting, dwell/click method]
  • Settings: [Gain, smoothing, dwell]
  • Performance: [Accuracy, speed, endurance]
  • Interpretation: [Suitability and constraints]
• Partner-assisted scanning: [Findings and rationale] (Include only if considered.)

Recommended primary access method: [Method with rationale based on performance, independence, and sustainability]

Recommended secondary/backup access method: [Method with rationale] (Especially important for progressive conditions.)

Language Representation and Vocabulary Needs

• Representation: [Objects, photos, symbols, text, bilingual output needs]
• Symbol size and navigation tolerance: [Optimal target size, items per screen, navigation steps tolerated]
• Vocabulary strategy: [Core vocabulary, fringe/topic sets, phrase banks, morphology/grammar supports]
• Message generation: [Pre-stored phrases, word prediction, abbreviation expansion, letter-by-letter, rate enhancement needs]
• Literacy supports: [On-screen keyboard, spelling supports, literacy scaffolds]
• Voice/output preferences: [Digitized vs synthesized, voice characteristics, intelligibility, rate, volume requirements]
• Feature-to-need linkage: [Each requested feature tied to observed participation need]

Feature Matching and Device Trials

Required features summary:

• Access compatibility: [Supports primary/secondary access with configurable settings]
• Display/interface: [Dynamic vs static, screen size, glare control, mounting compatibility]
• Language system: [Vocabulary systems, symbol sets, morphology, rate enhancement tools]
• Output: [Volume, clarity, voice options, remote messaging/phone integration]
• Portability/durability: [Weight, ruggedness, protective case options]
• Power management: [Battery life, charging options]
• Programming/maintenance: [Caregiver programming capability, backups, remote support]

Device/system trials: (For each device trialed, complete a block below. Distinguish dedicated SGDs from SGD software on general-purpose hardware. If formal trials did not occur, explain why and document the plan.)

• Device/System: [Device name and model] — [dedicated SGD / SGD software on general-purpose hardware]

  • Access method and settings: [Method, dwell/scan speed, target size, keyguard, switch type]
  • Language/vocabulary system: [System name, symbol set, customization performed]
  • Tasks completed: [Functional tasks reflecting daily needs]
  • Outcomes: [Effectiveness, efficiency/speed, accuracy, cueing required, fatigue, user preference]
  • Accept/reject rationale: [Tied to feature requirements and observed performance]
  • Feasibility considerations: [Caregiver capacity, environment, maintenance]

(Repeat device trial block for each additional device trialed.)

Clinical Impression

[Communication diagnosis, severity, and functional impact across environments. State why an SGD is needed now. For progressive conditions, describe anticipated changes. Include risks of not providing the SGD such as safety concerns and inability to communicate health needs.] (Attribute prognosis statements to medical records.)

Recommended AAC/SGD System

• Device/software: [Device name/model or software] — [dedicated SGD / SGD software on general-purpose hardware]
• Primary access method and settings: [Method, dwell/scan speed, acceptance time, target size, keyguard/switch details]
• Display size/layout and symbol system: [Screen size, grid size, symbol set, navigation structure]
• Voice/output configuration: [Voice selection, rate, volume, amplification]
• Required accessories: (Itemize each with model/specifications.)
  • [Wheelchair/table mount]
  • [Keyguard]
  • [Switch(es) and mounting]
  • [Eye gaze camera/module]
  • [Carrying case/protective case]
  • [Amplified speaker or docking station]
  • [Power/charging accessories, backup battery]
  • [Wheelchair interface/adapters]
• Device category/code: [Code/category per payer workflow] (Include only if required.)
• Backup communication plan: [Low-tech system and emergency communication strategy]

Medical Necessity Justification

(REQUIRED SECTION: Use clear, declarative statements directly supported by evaluation findings.)

• Current impairment and course: [Nature and severity of speech/communication impairment; course: stable / progressive / fluctuating with clinical sources]
• Why non-SGD options are inadequate: [Evidence-based reasons referencing findings from Assessment of Non-SGD Communication Options section]
• Functional goals achievable with recommended SGD: [Specific, measurable goals related to daily participation, safety, and healthcare communication]
• Why this system is the most appropriate match: [Feature-to-need linkage, access compatibility, language system fit, portability, durability]
• Why less complex/less costly alternatives are insufficient: [Specific limitations of alternative devices relative to patient needs and trial performance]
• Accessory justifications: (Itemize each accessory with medical necessity linked to functional limitation.)
  • [Accessory name]: [Medical necessity statement linking to specific functional limitation; why alternatives are inadequate]
• Training plan feasibility: [Availability of SLP services, caregiver/partner capacity, environment readiness, plan for setup/programming]

Treatment and Implementation Plan

• SLP services: [Frequency, duration, setting, modality: in-person / telepractice, anticipated start date]
• Operational competence targets: [Powering, charging, navigation, backups, troubleshooting, mounting]
• Linguistic competence targets: [Vocabulary growth, morphology/grammar, message generation, literacy supports]
• Strategic competence targets: [Repair strategies, rate enhancement, preparation for high-stakes interactions]
• Social competence targets: [Turn-taking, partner engagement, self-advocacy]
• Programming/customization plan: [Initial vocabulary selection, personalization schedule, backup procedures, remote support]
• Communication partner training: [Modeling, prompt hierarchy, aided language input, fading plan]
• Follow-up timeline: [Schedule to reassess access settings, positioning, vocabulary growth, device maintenance]
• Education provided: [Topics covered and confirmation of understanding]
• Anticipated barriers and mitigations: [Caregiver workload, transport, charging routines, sensory tolerance, staffing for modeling, risk management if device unavailable]

Referrals and Coordination

• [OT/PT for mounting, seating, or access endurance]
• [Vision/hearing evaluation]
• [Rehab engineering/ATP for complex mounting or alternative access]
• [Neurology/physiatry for course/prognosis documentation]
• [DME supplier coordination]

(Include only referrals that are needed or completed.)

Summary

[One-paragraph synopsis of communication needs, key findings, and recommendation]

• Recommended system components: [Device, access method, key settings, accessories]
• Training plan overview: [Key training targets and schedule]
• Next steps: [Submit report to treating practitioner, initiate loaner trial, finalize funding packet, schedule training/setup]

Signature and Attestation

SLP Signature: [Signature]

Name/Credentials: [Name, degree, credentials]

License Number/State: [License number, state]

NPI: [NPI] (If applicable.)

Date: [Date signed]

Independence attestation: [Statement confirming no financial relationship with device supplier and clarifying vendor role if applicable] (Include only if required by setting.)