UNIVERSITY OF SOUTH FLORIDA SPEECH-LANGUAGE-HEARING CLINIC
Communication Sciences and Disorders
4202 E. Fowler Avenue, PCD 1017
Tampa, FL 33620
Clinic Phone: 813-974-9844
Clinic Fax: 813-974-0822
Speech-Language Pathology (SLP) Daily Note and 10th Visit Progress Note
Client Name: JMVFNDD MRN: XXXX
SLP/Clinical Instructor: I.B. Trainin’, MS, CCC-SLP Date of Birth: XXXX
Graduate Student Clinician: I.B. Learnin’, BS Time In/Out: 1:04pm-2:00pm
Date of Service: 02-10-17 Visit Number: 40
Subjective:
Pain: 5/10; Using the pain scale the client pointed to 5 and indicated abdominal pain. Upon inquiry it was
determined pain was due to menstrual cramps and was confirmed by caregiver.
Medication Changes: Over the counter (OTC) medication for menstrual cramps.
The client was on time and engaged in therapy. She reported having a stressful day which affected her
performance during this session.
Objective:
Objective 1: The client will complete immediate recall activities, during structured tasks, with 80% accuracy and
occasional, moderate visual cues in order to improve independence during ADL activities.
Results: MET- The client completed an immediate recall activity with 100% accuracy with occasional, moderate
visual cues.
Objective 2: The client will use trained compensatory strategies to increase word finding skills with 80% accuracy
and occasional, moderate verbal and visual cues, in order to increase participation in functional conversations.
Results: PROGRESSING- Using Semantic Feature Analysis (SFA), the client named 75% of common objects, with
occasional, moderate verbal and visual cues.
Assessment:
The client demonstrated improvement from previous session in relation to accuracy of performance for immediate
recall tasks. The instructions were presented in written format; however, the client demonstrated difficulty in
understanding how to complete the task. The client benefited from having the instructions read aloud and
explained to him through a practice trial. The client’s accuracy then improved. Word finding continues to be an
area of deficit; however, semantic and phonemic cues are beneficial for moving the client towards target.
G-Codes: G9168, Current, Memory, CK; G9169, Projected Goal, Memory, CJ
Progress Summary: At baseline the client’s immediate recall was 100% accurate with consistent, maximal verbal
and visual cues. The client has progressed to 100% accuracy with occasional, moderate visual cues. Immediate
recall compensatory strategies have started to be introduced including Space Retrieval. Further trials are
warranted in order to report benefit. However, current strategies such as writing instructions for task and
repetition with explanation have been facilitative. The client’s baseline performance for word finding was 20%
accurate with consistent, maximal visual, verbal, and tactile cues. The client has benefited from instruction in use
of SFA strategy and is currently performing at 75% accuracy for common objects, with occasional, moderate verbal
and visual cues. The client’s caregiver reports the client has been asking for objects around the house by name,
and has offered additional items for grocery list. The caregiver has been trained on how to use phonemic and
semantic cues to facilitate word finding and has reported reduced client frustration during functional
conversations.
Daily Note Date: 2/10/17
Client Name: JMVFNDD
MRN: XXXX
DOB: XXXX
UNIVERSITY OF SOUTH FLORIDA SPEECH-LANGUAGE-HEARING CLINIC
Communication Sciences and Disorders
4202 E. Fowler Avenue, PCD 1017
Tampa, FL 33620
Clinic Phone: 813-974-9844
Clinic Fax: 813-974-0822
Plan:
Next appointment: 2/17/17 at 1pm. Continue focus on word finding strategies including SFA and Verb Network
Strength Training, as well as immediate recall tasks. Client to use word finding strategies in at least three different
occasions prior to next session, with assistance of caregiver, and report.
____________________________________________ __________________
I.B. Learnin’, BS Signature Date/Time
Graduate Student Clinician
_____________________________________________ __________________
I.B. Trainin’, MS, CCC-SLP Signature Date/Time
Speech-Language Pathologist
** Treatment provided was directed and supervised by the primary SLP 100% of the time on service date 3/14/17, while not
engaged in treating another patient or doing other tasks in order to direct the service, make the skilled judgement, and assume
responsibility for the assessment and treatment in accordance with Medicare and Medicaid guidelines. **
Daily Note Date: 2/10/17
Client Name: JMVFNDD
MRN: XXXX
DOB: XXXX
