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Reports

Reports. Multidisciplinary team is good. Not necessary, but gives fuller picture. Licensed provider (if neuropsychologist, board certified) Does report include: Basic contact information for provider

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Reports

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  1. Reports • Multidisciplinary team is good. Not necessary, but gives fuller picture. • Licensed provider (if neuropsychologist, board certified) • Does report include: • Basic contact information for provider • Basic information regarding patient/student/client (eg date of birth, age at testing, gender). • Specify the presenting problem/reason for referral • Background history from caregiver/provider intake interview? • Are previous findings from previous reports integrated or referenced? • Include testing and observations related to domains relevant to the presenting problems/chief complaint? • Behavioral observations • If so, in what context: clinic, school, home, community? • Include information from educators • If so, how? Questionnaire or interview? • Does report contain test scores, explained adequately and put in context for reader (eg, specify mean and standard deviation for the test). • Is there a summary section providing diagnostic picture and overall summary of patient • Does the diagnosis match the observations and picture painted in the body of the report • Educational and treatment recommendations that are delivered in teacher-friendly language • Are recs customized to individual profile or more tied to diagnosis (former is better) • Do recs generally follow from the testing or too speculative? • How specific are the recs? (eg, implement behavior plan on 15 minute intervals with BLANK reinforcers using a visual schedule VS start a sticker chart)

  2. Reports Continued • Ideally somewhere between 6-8 pages • Comprehensive yet concise speaking to referral question • In general should Include relative strengths/weaknesses found on testing, clear diagnostic impression, clearly outlined/practical recs for addressing the individual profile • Sections: • Identifying information and referral • Chief complaints • History of presenting illness • Other medical/psychiatric history • Family history • Social/Educational/Vocational history • Behavioral Observations (with mental status exam) • Test results (in table format with percentile scores, descriptors, specified by domain) • Summary of results • Diagnostic impressions • Recommendations

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