Module II: Evaluation and Assessment

 

 

Unit IV Lesson 1: Guidelines

 

Evaluation and Assessment Reports

 

In the context of the law and of Missouri’s criteria and process for determining if a child is eligible for First Steps, we have examined why evaluation and assessment are done. Once a provider has completed evaluation or assessment activities, he or she must compile all the information into a report. It is important for the report to be meaningful and un­derstandable to the parents. The “trick” to report writing is to translate professional jargon into language everyone can un­derstand while also documenting the results obtained. How does one do this? What should be included in the report?

 

Reporting Guidelines

The overall purpose of written reports is to communicate with other team members and professionals, including family members, the best estimation of a child’s abilities at a given point, as well as to serve as a record against which later performance can be compared. The following are descriptions of what quality components should look like for written reports.

 

Demographic Information:

Reports should include the name of the child, the child’s date of birth, the child’s chronological age, the child’s adjusted chronological age, if appropriate, the child’s diagnosed condition(s), if any, the suspected area(s) of delay, if any, the date of the evaluation or assessment, the date of the report, the location of the evaluation or assessment, and the examiner’s name Additional information may include the name of the family’s service coordinator.

Adjusted chronological age must be used at the point of eligibility if the child is being considered for First Steps eligibility based on developmental delay. It should also be used when interpreting Developmental Assessment for IFSP planning. It is calculated by deducting one-half of prematurity (based on 37 weeks gestation) from the child’s chronological age. It should be assigned for a period of up to 12 months or longer if recommended by the child’s physician. Example: If a child is born eight weeks premature, you would divide eight by two and then subtract four weeks from their chronological age. So if the child is 12 weeks old, their adjusted chronological age would be eight weeks.

 

Report Type/Purpose:

Content of the report should reflect the purpose of the evaluation or assessment. It should be clearly stated in the report whether the evaluation was conducted to help determine eligibility or the assessment was conducted to assist in IFSP planning. For example, an eligibility report will look different than an assessment report because different procedures and tools were used.

 

Family-Friendly Language:

Reports should include family-friendly language. If a provider would like to include clinical language in his or her report, it is important for that provider to include a description or an explanation of the clinical language that is easy for those with no clinical background to interpret and understand. The report must be written with sensitivity because it will be available to family members. This does not mean that issues should be ignored, but the conclusions should be described, qualified, and supported by the information that was obtained. In addition, personal comments are inappropriate.

 

Description of Evaluation for Eligibility or Assessment for IFSP Planning:

 

Instruments/Methods of Evaluation or Assessment Used:

In family-friendly language, list the tool(s) that was used. This can include information obtained from formal instruments, informal assessments, clinical observation, and family members. If the tool is a structured or semi-structured instrument, a brief description of the tool and the purpose of the tool should be included.

 

Description of Findings:

In general, the description of findings should include:

What the child can do or what he or she is beginning to do.

Additional information on the child’s daily routines that was provided by the family during the pre-evaluation or family assessment phase.

The child’s strengths and needs/current levels of development.

A description of any variations from standard assessment conditions.

If the purpose of the report is evaluation of eligibility, the information in this section should assist in determining if the child is a child with a disability or developmental delay and if he or she is eligible for early intervention (EI) services. Typically, the section will contain scores; however, remember that scores should not stand alone. Descriptive information should accompany scores. It is very important that the service coordinator have the necessary information regarding the degree of delay, so that an eligibility determination can be made.

If the purpose of the report is assessment for IFSP planning/intervention planning, this section should contain information that will assist the IFSP team in developing outcomes. For example, the information should describe what the child is beginning to do, areas of need, and what strategies might be appropriate to target areas of need.

 

Summary/Recommendations:

This section should summarize the information within the context of the report and discuss the child’s strengths and needs based upon the results.

If the purpose of the evaluation report was to determine eligibility, it may be appropriate for the professional to include additional information that summarizes his or her informed clinical opinion related to the developmental domains that were evaluated. This is particularly true if the test results (scores) clearly do not indicate the child meets the eligibility criteria for First Steps and the professional feels there are unique circumstances of characteristics that should be considered when determining eligibility. In this case, the basis for the informed clinical opinion that the child’s delays are significant enough to be considered a 50% or greater delay, absent the scores to support this, needs to be articulated thoroughly and clearly.

If the purpose of the report was assessment for IFSP planning, the professional should provide strategies or activities that could be incorporated into the IFSP to support the process of developing child/family outcomes. While the report may provide suggestions related to services and strategies, specific recommendations related to frequency and intensity of services are not appropriate at this time and should not appear in this report. The frequency and intensity of services will be determined at the IFSP meeting.

To ensure you have understood the ideas presented examples of actual reports written for FS are available. These have been changed to make them anonymous. Some of the sections are well done and others need to be improved.  Click here for this practice.

 

Review questions:

1. Why should jargon NOT be used in a report?

2. Should personal comments be used in a report?

3. If a child does not meet the 50% developmental delay criteria what are the options?

 

Reflection questions:

1. Why should it be "plainly stated" whether a report is for eligibility requirements or for IFSP planning?

2. The medical model depends on precise terms and phrasing that often result in jargon that cannot be understood by anyone other than the medical practitioner. Why should medical jargon NOT be used in FS reporting?

 

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If you have a question about this module please check the Q & A pages. If you still have a question after reviewing the Q & A pages please send an email to: webreplyspefs@dese.mo.gov or call 573.751.0187

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