Professional Predicaments

Answer:

Firstly, informed consent needs to be obtained before any assessment, intervention, or referral can go ahead (Standard of Practice 1.1). Part of obtaining consent for assessment is explaining what is involved, the risks, benefits and alternatives, and the client’s option to refuse or withdraw at any time (Standard of Practice 2.3).

Regulated members are responsible for selecting and administering culturally and linguistically appropriate assessments and interventions that comprise an evidence-informed, individualized approach, within their knowledge and competence (Standard of Practice 1.3). Since assessment findings form the basis of your interpretation and recommendations, it is important to perform due diligence by cross-checking and reviewing standardized scoring protocols or testing manuals to ensure results are accurate.

In summarizing your findings in an assessment report, providing explanations of standardized data and using appropriate, unbiased language, without jargon, will support the client’s and other readers’ understanding and engagement (Standard of Practice 4.3). Informal assessment and clinical observations may also provide valuable information that should be included, where relevant.

Documentation, including assessment reports, should be completed in a timely manner, as clients/families or other professionals may be relying on the information you provide.

Generally, an assessment report should include (not an exhaustive list):

• A relevant case history,
• Presenting concern(s) and priorities, including caregiver concerns, where relevant,
• Any adverse/unusual events or contraindications to assessment,
• Assessment(s)/screening(s) completed and the results,
• Analysis and clinical interpretation of the results obtained, (e.g., diagnosis, meaningful explanation of any assessment results),
• Strengths and needs relevant to communication, hearing, feeding and/or balance,
• Plan of care, including recommendations, interventions and progress, referrals, and discharge plans, and
• Name and professional designation of the person documenting the information and/or taking professional responsibility for the work.

Providing information in chronological order, or in a format that presents the most pertinent information first, can provide clarity. For further details on documentation requirements, refer to Standard of Practice 4.3 and ACSLPA’s Clinical Documentation and Record Keeping Guideline (page 11).

Regulated members are reminded that they may contact the College if they have questions or need further clarification. Please do not hesitate to reach out at any time using the Contact Us form.

If there is a conflict or discrepancy with the information or advice set out on this webpage and the information contained in a more official ACSLPA document, then the information contained in the more official ACSLPA document applies and not the information or advice set out here. For the purposes of this disclaimer, ACSLPA’s more official documents include the governing legislation (including the Health Professions Act and the Speech-Language Pathologist and Audiologist Profession Regulation) as well as ACSLPA’s Bylaws, policies, Standards of Practice, Code of Ethics, manuals and/or any other official document approved by Council, a statutory committee or a college official. Persons interacting with ACSLPA are responsible for reviewing and familiarizing themselves with the relevant information contained in ACSLPA’s official documents.