21 / 44
ACQ
uiring knowledge
in
speech
,
language and hearing
, Volume 10, Number 2 2008
55
Work– l i f e balance : preserv i ng your soul
SATURDAY
SUNDAY
Patient unable to be seen due to:
_ ___________________________________________________
Other relevant information:
_ ___________________________________________________
_ ___________________________________________________
_ ___________________________________________________
_ ___________________________________________________
_ ___________________________________________________
On Monday this patient:
Needs a swallowing review
Needs initial swallowing assessment
Needs communication assessment
Needs education regarding:
____________________________________________________
Needs liaison with:
____________________________________________________
Other (please specify)
____________________________________________________
COMPLETED BY THE PATIENT’S USUAL SPEECH PATHOLOGIST:
Feedback from service provided on Monday:
Swallowing
Patient placed NBM
Patient commenced oral feeding
Diet was upgraded
Diet was downgraded
Patient reviewed with no change to diet
Change to patient’s recommendations:
Improvement/deterioration in medical condition (give details):
Commenced/continued swallowing therapy (give details):
Other relevant information (eg: feeding strategies, carers/family issues, compliance, progress discharge planning)
Communication
Assessment conducted
aphasia
dysarthria
dyspraxia voice
Assessment type:
informal
formal (give details)
Therapy – focusing on:
Other relevant information: (eg: information provided to family/carers, handouts given, exercises given, etc)
SPEECH PATHOLOGY PLAN:
MRN: _ _____________________________________________ DOB: ____/ ____/ _____
Surname: _ __________________________________________ First Name: _______________________
Street: _ _____________________________________________ Suburb:_____________________________ Postcode: ______
(Insert medical record sticker)
Appendix B. Speech pathology patient database
Telephone:
NOK: ___________________________________
Medical Officer:
LMO: ___________________________________
Speech Pathologist:
DVANo: _________________Wt
o
� Gold �
o
Date Referred: ____/____/____ (by _____________ )
Reason for Referral: ___________
Date 1st seen: ____/____/____ ICD – 10 Completed �
o
Therapy Diagnosis: _____________________________________________________________________________________________
Medical Diagnosis: _____________________________________________________________________________________________
CLINICAL INFORMATION:
Date Discharged: ____/____/____
Discharge Destination: _______________________________