Speech-Language Pathology Initial Evaluation Report (Outpatient Medical)

Patient Name: [Patient full name]

Date of Birth: [MM/DD/YYYY]

MRN: [Medical record number]

Date of Service: [MM/DD/YYYY]

Location: [Clinic name]; [in-person / telehealth]

Evaluating Clinician: [Name, credentials]

Referring Provider: [Name, credentials, clinic]

Referral Date: [MM/DD/YYYY]

Primary Medical Diagnosis(es): [Medical diagnoses related to referral]

Accompanied By: [Names and relationship] (Include only if patient accompanied by family/caregiver.)

Interpreter Used: [Language and mode] (Include only if interpreter used; omit line entirely if none.)

Reason for Referral

[Referral reason, clinical question, chief complaint, symptom onset and course, and any immediate safety concerns] (2–5 sentence narrative. Include patient quote if available. Note precipitating event such as procedure or illness. Document safety concerns such as aspiration risk, weight loss, choking, or airway compromise.)

Relevant History

Medical/Surgical History: [Pertinent neurologic, respiratory, reflux/GI, head/neck, and intubation/tracheostomy history] (Include only history relevant to communication, swallowing, voice, or cognition. Label information sources: patient report, caregiver report, chart review, or outside records. Use "Unknown" or "Unable to obtain" with brief reason for critical missing data.)

Medications (selected): [Medications affecting alertness, saliva, voice, swallow safety, cognition, or motor control] (Reference "full list per chart" if extensive. Spell out medication names without ambiguous abbreviations.)

Prior Level of Function (PLOF): [Functional communication, swallowing, voice, and cognition prior to onset]

Current Functional Status: [Current abilities and supports in home, work, and community contexts]

Prior Therapy: [Prior SLP or related therapies, dates, focus, and response] (Include setting and outcomes if available. Omit if none.)

Social Context: [Living situation, primary communication partners, caregiver availability, work/academic demands, communication environments]

Hearing/Vision: [Functional hearing and vision status; devices used and effectiveness]

Patient/Caregiver Goals: [Patient-stated goals and priorities; caregiver goals if relevant]

Assessment Methods

• Information Sources: [Interview / chart review / caregiver interview / outside records]
• Standardized Measures: [Test name and version; administration language; modifications with rationale] (Omit if none used.)
• Non-Standardized Measures: [Clinical tasks and rating procedures]
• Testing Conditions/Validity: [Factors affecting validity: fatigue, sensory limitations, attention, language differences, session length]

Objective Findings

(Include only subsections relevant to the referral and assessment. Always include General Observations. Omit entire subsections if domain not assessed and not indicated.)

General Observations

• Arousal/Alertness: [Level of arousal and consistency]
• Affect/Behavior: [Affect, cooperation, task persistence]
• Orientation: [Person / place / time / situation]
• Insight/Awareness: [Insight into deficits and safety awareness]
• Communication Modality: [Spoken language / gestures / writing / AAC; primary languages]
• Speech Intelligibility: [Estimated intelligibility; contexts affecting understanding]
• Functional Hearing/Vision: [Observations impacting assessment or communication]

Oral Mechanism

(Include if assessed. If deferred, state reason briefly.)

• Dentition/Oral Mucosa: [Dentition status, oral mucosa integrity, hygiene]
• Secretion Management: [Saliva management adequacy]
• Structure/Function: [ROM, strength, coordination, symmetry of lips, tongue, jaw, soft palate]

Speech / Motor Speech

(Include if assessed.)

• Articulation: [Phoneme accuracy, error patterns]
• Rate/Prosody: [Rate, stress, rhythm]
• Respiration–Phonation Coordination: [Breath support, coordination]
• Dysarthria/Apraxia Characteristics: [Perceptual features if present]
• Intelligibility Estimate: [Overall estimate; factors improving or worsening intelligibility]
• Standardized Measures: [Measure name/version — score/metric — severity interpretation — validity considerations] (Include if administered.)

Language

(Include if assessed.)

• Auditory Comprehension: [Single-word, sentence, multi-step, discourse-level; error patterns]
• Verbal Expression: [Word finding, fluency, syntax, discourse organization; qualitative errors]
• Reading/Writing: [Decoding, comprehension, spelling, written expression] (Include if relevant to referral.)
• Standardized Measures: [Test name/version; administration language; scores with interpretation; validity considerations] (Include if administered.)

Cognitive-Communication

(Include if assessed.)

• Attention: [Sustained, selective, alternating, divided; functional impact]
• Memory: [Immediate, working, delayed, prospective; strategy use]
• Executive Functions: [Planning, organization, initiation, inhibition, problem solving, flexibility]
• Awareness/Safety: [Error monitoring, judgment, insight]
• Functional Impact: [Medication management, finances, appointments, safety tasks]
• Standardized Measures: [Measure name/version — scores — severity interpretation — validity considerations] (Include if administered.)

Voice / Resonance

(Include if assessed.)

• Perceptual Quality: [Breathy / strained / rough / pressed / hoarse / other descriptors]
• Loudness and Pitch: [Habitual loudness, pitch, variability]
• Phonatory Effort: [Observed effort or strain]
• Vocal Use History: [Daily demands; phonotraumatic behaviors]
• Stimulability: [Response to trialed techniques]
• ENT Referral: [Recommended / not indicated] (If recommended, state rationale.)

Fluency

(Include if assessed.)

• Core Behaviors: [Repetitions, prolongations, blocks]
• Secondary Behaviors: [Physical concomitants, avoidance, circumlocutions]
• Variability: [Contexts that increase or decrease disfluency]
• Participation Impact: [Activities and roles affected]
• Measures: [Fluency counts, severity ratings with interpretation] (Include if administered.)

Swallowing

(Include if assessed.)

• Swallow History: [Baseline diet, current diet, symptoms, compensatory strategies, hydration/nutrition concerns] (Use IDDSI levels for diet consistencies.)
• Clinical Swallow Evaluation: (Include if bedside/clinical evaluation performed.)
  • Positioning: [Position, supports, respiratory status, O2 needs]
  • Oral Trials: [Consistencies tested, volumes, method of delivery]
  • Oral Phase: [Lip seal, mastication, bolus control, oral residue]
  • Pharyngeal Phase: [Swallow initiation, laryngeal elevation, signs of difficulty]
  • Safety Indicators: [Cough, throat clear, wet vocal quality, respiratory changes]
• Impressions and Recommendations: [Risk assessment; diet and liquid recommendations using IDDSI; supervision and feeding strategies; need for MBSS/FEES with rationale]

AAC / Communication Supports

(Include if assessed.)

• Current System: [Low-tech / high-tech systems; symbol sets; language systems]
• Access Method: [Direct touch / stylus / eye gaze / switch / partner-assisted scanning]
• Trials and Response: [Devices/apps tried; accuracy, speed, user preference]
• Partner Training Needs: [Caregiver strategies and training requirements]
• Environmental Factors: [Barriers and facilitators]

Functional Impact Summary

(Align with ICF model. Translate impairments into real-world consequences.)

• Impairments (Body Functions/Structures): [Key deficits with severity: mild / moderate / severe]
• Activity Limitations: [Specific tasks affected: phone conversations, following medical instructions, meal preparation, eating safely, etc.]
• Participation Restrictions: [Impact on work/school, social participation, independence, safety]
• Environmental Factors: [Barriers and facilitators: caregiver support, language access, assistive devices]
• Personal Factors: [Motivation, coping, readiness for therapy, health literacy]

Clinical Impression

[Summary integrating history, objective findings, and functional impact; primary diagnosis with severity; relationship to medical diagnosis; rationale for skilled SLP services]

• Primary SLP Diagnosis(es): [Diagnosis and severity]
• Differential Considerations: [Differentials and rationale] (Include only if diagnostic uncertainty exists.)
• Patient Strengths: [Abilities and supports enhancing prognosis]
• Skilled Need Justification: [Why skilled SLP services are medically necessary: complexity, safety risk, clinical judgment required, caregiver training needs]

Prognosis

• Prognosis Rating: [good / fair / guarded / poor] — [Brief rationale]
• Positive Prognostic Factors: [Motivation, support, stimulability, early referral, etc.]
• Barriers/Risk Factors: [Progressive disease, cognitive impairment, sensory loss, attendance concerns, etc.]
• Expected Functional Gains: [Measurable gains anticipated] within [time horizon]

Recommendations and Plan of Care

Therapy Recommendation: [Outpatient SLP recommended / Not recommended] — [Rationale] (If not recommended, specify: within normal limits, not medically necessary, patient declines, or refer elsewhere.)

Plan of Care Parameters: (Include if therapy recommended.)

• Intervention Focus Areas: [Primary domains and targeted skills]
• Frequency: [Visits per week]
• Duration: [Weeks or total visits]
• Anticipated Discharge Timeframe: [Estimated timeframe]
• Service Delivery Model: [individual / group]; [in-person / telehealth]; caregiver training: [yes / no]
• Re-evaluation Plan: [Timing and measures for progress review]

Goals

(Functional, measurable goals with target behavior, conditions, accuracy criterion, timeframe, and functional rationale.)

Long-Term Goals:

• [LTG 1: Functional target + conditions/supports + accuracy criterion + timeframe + functional rationale]
• [LTG 2: Functional target + conditions/supports + accuracy criterion + timeframe + functional rationale]

Short-Term Goals:

• [STG 1: Task + conditions/cues + measurable criterion + timeframe]
• [STG 2: Task + conditions/cues + measurable criterion + timeframe]
• [STG 3: Task + conditions/cues + measurable criterion + timeframe]

Education and Home Program

• Education Provided: [Topics covered; recipient(s); comprehension verified via teach-back or return demonstration]
• Home Practice: [Specific exercises/strategies with dosage and safety parameters]
• Materials Provided: [Handout titles or resources] (Omit if none.)

Referrals and Coordination

(Include only referrals made or recommended.)

• Instrumental Assessment: [MBSS / FEES] — [Rationale]
• Other Referrals: [Audiology / ENT / Neuropsychology / Dietitian / OT / PT / Other] — [Rationale]
• Care Coordination: [Communication to referring provider; method and date]

Discharge Criteria

[Goals met; plateau without measurable benefit; transition to maintenance or alternate level of care; patient preference or change in medical status]

Clinician Signature

______________________________
[Clinician name, credentials, professional designation]
Date/Time Signed: [MM/DD/YYYY HH:MM]