1. BrICC Brain Injury & Concussion Center Oral Case Reporting
2017
Communication Disorders & Sciences University of Oregon

2. Rationale
Master professional communication and reporting skills to facilitate participation in medical rounds meetings
Further develop rational clinical decision making skills

3. Development of Skills Clinical Decision Making Reporting
“Clinical knowing”
Reporting
“Saying what you know”

4. Types of Reporting Case Introduction
Medical diagnosis (i.e. etiology)
Treatment diagnosis
Client/caregiver’s presenting concern
Previous history treatment
Treatment goal
Client Progress/Update Goal/Target
Approach
Measurement

5. Initial Case Introduction
Medical diagnosis (i.e. etiology)
Treatment diagnosis
Client/caregiver’s presenting concern
Previous history of treatment
Current outcome goal of therapy including
Goal
Approach
Desired Outcome

6. Initial Script Example
J is a 26 year-old male who presents with cognitive-communication deficits, including impairments in attention and working memory post- traumatic brain injury that resulted from a motor vehicle accident 6 months prior to his initial visit to BrICC.
J’s primary concern is his difficulty with attention and memory in terms of keeping up with the demands of his current job in office management.
J received 2 weeks of inpatient rehabilitation focused primarily on ADLs (activities of daily living). Treatment focused on orientation and introduction of memory strategies. This is J’s first term at BrICC.
Current goals for therapy including improving sustained attention and working memory though direct attention training in order to meet current job demands and decrease forgetting episodes at work.

7. Examples...and Non-examples
Mrs. Smith is a 73 year-old female, 6-months post left hemisphere CVA who presents with right hemiparesis and moderate non-fluent aphasia.
Mrs. Smith’s primary concern is her difficulty communicating wants and needs to her caregiver and initiating conversation with her grandchildren.
Mr. Jones experienced a severe traumatic brain injury resulting from an assault in May 2008.
What’s missing?
Neuropsych testing suggests deficits in sustained attention, speed of processing and new learning.
So what?

8. Initial Case Report Components
Medical diagnosis (i.e. etiology)
Treatment diagnosis
Client/caregiver’s presenting concern
Previous history of SLP

9. Update Report Example
This term we are focusing on improving attention, working memory and recall of new information through direct process training (APT) and metacognitive strategy training targeting study skills.
Treatment progress is being measured by an increase in accuracy and decrease in response time on APT exercises and level of cueing required for study agenda generation. Impact progress is being measured by an increase in performance on the PASAT, an improved completion rate of classroom assignments/tests at a grade of B or higher, and self-report of improved focus while doing homework.
Results from our last session showed steady improvement in accuracy on APT accuracy but no change yet in speed of processing. Outcome measures show a 50% assignment completion rate increased from a baseline of 20%, with average grade of C. Self-report of homework focus was a 2 on a five point scale, with 1 being no focus and 5 being “stellar focus.”
The plan is to continue with APT exercises targeting alternating attention, to refine the homework set-up and self-monitoring .

10. Final Report Example
This term we focused on improving attention, working memory and recall of new information through direct process training (APT) and metacognitive strategy training targeting study skills.
Treatment progress was measured by an increase in accuracy and decrease in response time on APT exercises and level of cueing required for study agenda generation. Impact progress has been measured by an increase in performance on the PASAT, an improved completion rate of classroom assignments/tests at a grade of B or higher, and self-report of improved focus while doing homework.
Since this was M’s 7th week of APT exercises, the PASAT was re-administered and showed a 2 standard deviation improvement from the start of the term. Results from our last session showed an 90% homework completion rate with grade B or higher. This is M’s 3rd week at this level. M consistently reports a focus level of 4, and increase from 2 at the start of the term. However, M reports he often feels pressure to stop studying to complete home chores. He states he starts and stops chores, losing track of what’s been done, and that this is an area he would like to improve.
As M’s LTG targeting study skills has been met, the plan is to discontinue APT exercises and study strategy training. M would like to start a new LTG related to completing home tasks which will be targeted via goal management training.