Module II: Evaluation and Assessment
Practice reports
The purpose of this exercise is to have you think in terms of natural environments and providing services to families. This learning is demonstrated with every report that is written. The overall purpose of writtten reports in FS is to communicate with other team members, including family members, the best estimation of a child's abilities at a given point. Evaluation and assessment reports are meant to be used to help determine a child's eligibility or provide information for IFSP development. It is important to remember that reports in FS are not written in technical or medical jargon; they must be meaningful and understandable to parents. In order to strengthen the lessons the following three sample reports are given. Please work through each one as instructed.
For practice, three reports follow. All identifying information has been removed from these reports. Of the first two example reports, one was written for eligibility determination while the other was written for IFSP planning and development. These two reports have sections that need improvement. The third report is generally good in all areas of reporting. However, none of these reports are meant to be exemplar reports and are not meant to be used as templates.
Please read all three reports. When you read the first and second reports focus on what could be done better. When you come to the links following sections of the report give yourself a few minutes to think about what could be improved based on the information in the Reporting Guidelines given to you in the module. When you have a firm idea of what could be done better click on the “for suggestions” link to check your ideas. Keep in mind that while the Reporting Guidelines provide descriptions of what is best practice to include in written reports, the components included in evaluation and assessment are not mandated by state or federal regulations.
Report for Evaluation – SPEECH
Name: Holly Summers
Date of Birth: 2/22/01
Chronological Age: 20 months
Date of Evaluation: 5/25/03
Examiner: Marcie Reece, Speech/Language Pathologist
1. Demographic Information - for suggestions mouse over here.
Purpose of Evaluation: The purpose of this evaluation is to determine eligibility for First Steps.
2. Report Type/Purpose - for suggestions mouse over here
Updated information: The Summers’ no longer have a telephone; however, a message can be left with Ann Summer, Holly’s Aunt. Mrs. Summer has an audiology appointment scheduled for next week. She will have results sent to the service coordinator. Holly’s medical history is significant for food allergies and reflux. There are no concerns with her vision at this time. Mrs. Summers reported bleeding in her third trimester with bed rest and normal vaginal delivery.
Parent Concerns: Mr. and Mrs. Summers are concerned about Holly’s hearing and about her inability to talk. Mrs. Summers is also concerned because Holly screams and bangs her head when she becomes upset.
Description of Services: Holly was evaluated at her grandparents’ home in Clark County. Several people were present including Holly’s mother, sister, grandmother, grandfather, aunt, uncle, and several cousins. The results of this evaluation were based on interactions and observations.
3.a. Description of Evaluation - for suggestions mouse over here.
3.b. Description of Evaluation, medical - for suggestions mouse over here.
Cognitive: Upon arrival, Holly was playing with her family. As the session began, Holly ran to her mother and began to cry. However, after a few minutes, she began to venture away from her mother, grab a toy, and run back over to her mother. By the end of the session, Holly seemed less frightened by the evaluator. Holly will hug a doll and pretend to drink from a cup. She responded to her name when her grandmother called and responded well to other typical sounds in and around their home. She will copy a familiar gesture. Holly can turn a container upside down to get a small item and can activate buttons on mechanical toys. Holly will briefly look at pictures in a board book, but then will usually chew on the book. She required prompting to follow through with specific requests made by her mother and the examiner.
Language: It is estimated that Holly has a significant delay (42%) in language. Holly appears to understand some of what is said to her. She will briefly stop what she is doing when told “no-no.” She will sometimes follow a simple request such as throwing the trash away, coming when called, and responding to “get the ball.” She says “uh-oh”, “meow,” “hot,” “mom,” and “dad.” She will shake her head “no.” Holly understands others pointing, holds her arms up to be picked up, shouts for attention, and points to something that she wants. Holly appears to be able to produce many consonant sounds and will vocalize when playing.
Motor Skills: Holly walks securely, although Mrs. Summers describes her as “clumsy.” She walks with a slightly wide stance but falls over items on the floor. Holly can carry a toy while walking and will walk downstairs with one hand held. She can climb into an adult chair, turning around to sit. She is able to throw a ball forward. Holly can ride on a toy without pedals but prefers to be pushed. She seems to be visually alert, regarding objects both close and distant. Holly can pick up small items using the tips of her thumb and her index finger. She can turn pages on a board book, clap her hands and point with her index finger. She has limited experience with crayons and prefers to chew on them.
Social/Emotional: After Holly became comfortable with the testing situation, she began to run around the room and to play with toys and other people. She returned to her mother when she felt threatened, but played with her uncle, grandfather, and grandmother. Holly briefly attended to a mirror image of herself, then returned to playing ball with her uncle. She sometimes responded to her name by turning her head, and she sometimes would provide brief eye contact. Holly was affectionate with her mother, demonstrated jealousy by insisting on being held when her mother was holding an infant cousin, and seemed to enjoy being the center of attention of family members, even though she avoided attention from the examiner.
Self-Help: Holly can remove her socks and can cooperate with dressing by extending her arms and legs. However, she is afraid of hats, even on other people. She eats a late breakfast (she will spit up if fed too early) and chews with coordinated movements. Holly uses both a bottle and a sippy cup and can drink from a cup held for her. She is learning to hold a spoon, but needs assistance to feed herself. She sleeps in a car seat 10–12 hours at night, sometimes taking an afternoon nap. Holly explores cabinets and will “help” her mother by throwing away trash.
4. Instruments/Methods of Evaluation Used - for suggestions mouse over here
5. Family-friendly language - for suggestions mouse over here
6. Description of Findings - for suggestions mouse over here.
Summary: Holly is a 20-month-old girl who shows delays in all developmental areas. Her most significant delay is in language. Cognitive delays may be compounded by her lack of communication. Because Holly does not clearly demonstrate a half-age delay but did demonstrate a 42% language delay, as well as notable delays in all other areas, it is the professional opinion of this examiner that the team seriously consider extending their informed clinical opinion to justify Holly’s eligibility for First Steps. If it is determined that she is not eligible at this time, this examiner would recommend that Holly be evaluated again, no later than 6 months from now, to determine if she does qualify at that time. The family is particularly concerned about the possibility of a hearing loss and her inability to talk. The temper tantrums appear to be serving as a means to communicate her needs and to protest undesirable situations, tasks, etc. This examiner is concerned that if Holly does not develop some effective means of communication soon, her frustration will intensify, possibly resulting in more serious physical harm to herself. Also, the family is receptive to, and in need of guidance for, help with behavioral issues.
7.a. Summary/Recommendations - for suggestions mouse over here.
7.b. Summary/Recommendations - for suggestions mouse over here.
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Read the following report for ASSESSMENT - PT and think about what can be improved. For suggestions on improvement move the mouse over the links.
Name: Julie Smith
Date of Birth: 2/4/03
Chronological Age: 4.5 months
Adjusted Age: 4 months
Evaluator: Andrew Rodreguiz, RPT PC, MEd, BHS; BS
July 14, 2003
1. Demographic Information - for suggestions mouse over here.
2. Report Type/Purpose - for suggestions mouse over here.
Julie was seen in her home with her mother and father both present. Mr. and Mrs. Smith have reported to me the history of Julie since her birth and hospitalizations and surgeries. Mr. and Mrs. Smith indicated that Julie was born one month early and had developed toxemia in utero. Mrs. Smith indicated that Julie was in the ICU for 4.5 months right after birth. Mrs. Smith indi cated that Julie has had 6 different types of surgeries. Mrs. Smith also indicated that Julie had mandibular distraction. Mrs. Smith indicated that Julie is on constant oxygen and has a feeding tube. Mrs. Smith indicated that Julie has ASD. Mrs. Smith indicated, however, that a cardiologist at Grace Hospital said that the ASD appears to be improving and closing. Currently, the doctor that is working with Julie mostly is Dr. Hunter at Grace Hospital. They are also working with Dr. Flange, a pediatrician at Grace Hospital. Their own pediatrician is Dr. Benitez. Mr. and Mrs. Smith indicated that Julie will be evaluated by a neurologist very soon.
3.a. Description of Medical Assessment - for suggestions mouse over here.
3.b. Description of Assessment - for suggestions mouse over here.
ROM evaluation: Shows Julie to be within functional range with all of her fingers and her arms and legs with some tightness with both knees and ankles.
Tone: Shows Julie to generally exhibit fair muscle grade with upper and lower extremities bilaterally.
Reflex assessment: Shows Julie to exhibit mild left facing asymmetric type neck reflex (ATNR). Julie however is able to turn her head to the right side and to reduce the left facing ATNR. Julie also shows plantar grasp reflex and palmar grasp reflex bilaterally.
Developmental assessment: Shows Julie to be functioning at a newborn level of 0 months, according to the E-Lap. Since her chronological age is at 4 months adjusted, this therefore puts Julie at about 4 months delayed at this time. Since she is 4 months adjusted age, this therefore puts Julie 50% significantly delayed according to the E-Lap.
Behavioral observation: Shows Julie to have very poor head and trunk control and very little or no sitting balance at all, even when propped up. Julie has a g-tube for feeding purposes. Other behavioral observations show Julie to be unable to log roll at all and to have an extremely difficult time being prone on her stomach.
4. Family-friendly language - for suggestions mouse over here.
5. Instruments/Methods Used -for suggestions mouse over here.
6.a. Description of Findings - for suggestions mouse over here.
6.b. Description of Findings Report - for suggestions mouse over here.
Recommendation: It is my recommendation that Julie receive physical therapy services once a week for developmental stimulation to narrow the developmental delays. Her family will have difficulty following through with instructions.
7.a. Summary/Recommendations family friendly language. - for suggestions mouse over here.
7.b. Summary/Recommendations. - for suggestions mouse over here.
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The report below is an example of a well planned and prepared report.
Name: Emmit Johnson
Date of Birth: 6/27/01
Chronological Age: 16 months
Adjusted Age: 15.3 months
Diagnosed Condition(s), if any: none
Suspected Area(s) of Delay, if any: cognitive and motor
Date of Assessment: 10/28/02
Date of this Report: 10/29/02
Examiner: Casey Glass, M.S.
Service Coordinator: Jennifer Vandike
Report Type: IFSP planning and development
Purpose of Assessment: This assessment was requested by the IFSP team on 10/22/02 to determine unique developmental strength and need areas for IFSP planning and development. The family has recently moved to Scott County from the Springfield area, where they were participating in First Steps. In Springfield, Emmit was receiving physical therapy and occupational therapy as part of his IFSP and was soon to begin developmental therapy. Emmit is scheduled to have a physical therapy assessment and an occupational therapy assessment due to muscle weakness. Emmit was born 3 weeks premature. For additional background history and health information, please refer to information that is on file with First Steps.
Description of Services: Emmit was administered the Hawaii Early Learning Profile during the afternoon of 10/28/02 in his home. Emmit’s mother was present along with Emmit’s half-brother (preschool age), half-sister (infant), and a neighborhood child (preschool age). Near the end of the assessment, Emmit’s older sisters came home from school and also contributed infor mation about Emmit’s activities and behaviors. The results of the profile were obtained though direct observation, interaction, and an interview with Mrs. Johnson. Emmit seemed comfortable and allowed this examiner to hold and interact with him. He was active during the assessment, but Mrs. Johnson noted that he did not seem to be feeling well and was a little less active than usual. The percentages of delay and the estimated developmental age are derived from the scores on the Hawaii Early Learning Profile and based on Emmit’s adjusted age for prematurity.
Cognitive (Thinking Skills): Estimated developmental age is 6 months (60% delay). Emmit attended to the toys presented to him and was able to hold onto two objects. When handed another object, he did not drop one to grasp the third one. He had difficulty grasping objects with his right hand, and Emmit explored most toys by mouthing them. Emmit was very interested in crumbling paper and trying to put it in his mouth. He is usually very active, especially in his rolling walker, which he will maneuver around the house. While Emmit did not remove a cloth placed on his head, he grinned broadly when this examiner uncovered his head and said “Where’s Emmit? Peek-a-boo!” He likes to look at books, but he has no particular favorite toys. Emmit does, however, like toys with sounds; he can localize sounds by turning his head to the side. Several times he leaned over and gave his mother a kiss when she asked. Emmit seems ready to activate toys by pushing large buttons or banging and to explore toys with different shapes, textures, and noises.
Language: Estimated developmental age is 8.5 months (44% delay). Emmit attends to others by laughing, smiling, and bab bling, but especially does so with his mother and older sisters. He attends to noisy toys and turns his head when his name is called. He knows what “no” means. Emmit says “mamma” and babbles other consonant syllables (da-da-da-da). He will shout for attention and also squeals and grins broadly. Emmit acted excited to see his sippy cup with milk and reached for it. He will show frustration and “holler” especially when his walker gets stuck and he is trying to go somewhere. Emmit is ready to begin to mimic gestures (bye-bye, patty-cake) and communicate some basic wants, such as lifting his arms to be picked up.
Motor: Emmit is receiving a physical and occupational therapy assessment; therefore, this area was not tested.
Social/Emotional: Estimated developmental age is 8 months (48% delay). Emmit appeared very secure and happy during the assessment. Mrs. Johnson describes him as a “very good boy” and “easy going.” He attended to this examiner and explored my features with his hands. Emmit grinned at reflections of himself. He recognizes a variety of people and seems to discriminate familiar and unfamiliar people. Emmit does not have favorite toys, but rather likes most everything. He laughed heartily when “scared” by his sister when she jumped out of the closet at him. He smiled readily at both his mother and the examiner, and he frequently turned to grin at his mother during the course of the examination. Emmit seems ready to begin playing cooperative game playing, such as peek-a-boo and patty-cake.
Self-Help: Estimated developmental age is 8 months (48% delay). Emmit eats table food well and is beginning to self-feed some foods. He has some difficulty grasping and getting the food to his mouth. He drinks from a sippy cup with handles and holds it himself. Emmit generally takes two naps a day and sleeps well through the night without waking. He needs prompting to cooperate in dressing or diapering. Emmit should continue to self feed small soft chunks of food. He indicates a readiness to assist in undressing by responding to his mother saying “hands up!”
Summary: Emmit is a 16-month-old boy who has significant delays in all areas and is functioning at about a 6- to 8-month-old level. He is slowly developing skills despite the challenges posed by his muscle weakness. His relative strengths are in the areas of language, especially receptive, self-help, and social-emotional behaviors. His relative areas of need are in cognitive and motor skills. It is felt that some of the delays noted in cognitive development may actually be reflective of his expressive language and physical delays. It should be noted that Kevin was not feeling well on the day of the examination and was less responsive than can be usually expected. Emmit's mother verified that although he was less active and reponsive than usual during his evaluation he had performed as he typically does on days when he is feeling well. Mrs. Jackson expressed concern about his rolling walker, noting that he was outgrowing it. Mrs. Jackson plans to enroll Kevin in Parents as Teachers and is interested in information on daycare centers in the area.
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