APPENDIX 21
SUGGESTED FORMAT FOR DEVELOPMENTAL CASE REPORT
ADMINISTRATIVE DETAILS.
This is the front cover for the report.
Client’s name
Sex; age (not d.o.b.)
Take care re. confidentiality: use the first initial ONLY
School attended
Not the name but the type of school e.g. resource base
Clinic
Not the name but the type of clinic e.g. health centre
Referral details
Who referred the child to SLT (role or professional title, not
name) and the child’s chronological age on referral
SLT contact
Age of child on first SLT contact and number of sessions/blocks
of therapy received before student input. When they occured
Student contact
Age of child in first student contact. Total number and type of
sessions e.g. 4 sessions- 1 assessment and 3 therapy.
Communication
difficulty & indication
of severity
Medical diagnosis (if
applicable)
SUMMARY OF PAST INFORMATION (New page)
Information should be presented succinctly outlining significant factors only. (Use of bullet
points would be appropriate here)
Indicate the source of the information you present, for example SLT notes, information
obtained by student during interview with parents, family members or caregivers.
The information you present might include:

personal history;

family and social background;

medical history;

history of the present problems (e.g. how the problem has changed over time, family
attitudes to the problem and solutions that have been attempted by carers and the
results of these….);

investigations by specialists (e.g. summaries of assessment results that were available to
you before contact with the client; it may be appropriate to express this information in a
table or graph);

summary of previous SLT.
APPENDIX 21
DETAILS OF STUDENT’S OWN WORK
Initial observation of
speech, language and
behaviour (including
play, interaction and
general development)
Here set out YOUR initial observations gained over the
first couple of sessions only: do not include information
acquired several weeks into the client’s management.
Behaviours should be recorded in context and judgemental
terms avoided. Sub headings can be used for the different
aspects of the client’s behaviour.
Interpretation of initial
observations
Here outline briefly YOUR initial interpretation of the
significance of the behaviours observed. Again, these are your
initial interpretations: do not include impressions which were
formed or conclusions which were drawn at a later stage in the
client’s management.
Assessment selection
and results.
Give an account of the assessments selected and the rationale
for your choice. This rationale should take account of
limitations of the approach taken, as well as advantages.
If the assessments have already been carried out by someone
else without an in-depth analysis of the results, you may
undertake this yourself and include these analyses in this
section as your own work.
Set out a full summary of all assessment results. If for clarity
you need to illustrate your account with examples then do so,
but any further raw data which you may feel it is necessary to
include should go in the appendices.
If all assessments and in-depth analysis have been carried out
by someone else all this information should be included in the
Summary of Previous Information, but you will need to explain
clearly in this section why no further analysis was appropriate.
Conclusions regarding
overall findings.
Give a brief summary of the presenting problem and the
conclusions you were able to draw at this point in time
(including, if appropriate, a differential diagnosis). Make it
clear how these conclusions arose from the findings and
assessment results you have presented.
Your conclusions should take account of all currently relevant
results whoever has carried out the assessments.
APPENDIX 21
DECISIONS REGARDING MANAGEMENT , WITH SUPPORTING RATIONALE
The rationale provides your reasoning behind your management decisions. It informs the
reader WHY you have chosen a type of intervention to manage the child’s Speech,
Language and Communication needs.
Following this, the next part of the section sets out, and explains the reasoning behind your
management decisions. These will be based on:
a) the information gathered so far
b) relevant theory and literature.
Your rationale must make it absolutely clear how these two sources were used to guide your
thinking, and state clearly the decisions they led you to and the conclusions you drew. This
means that you must, for example,
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make the links between your decisions and your previous findings explicit
name the theoretical frameworks you drew on and show clearly how you applied
them to this client’s data
cite the literature you used to guide you (including any relevant efficacy studies) and
explain how it influenced your decisions
state your hypotheses
explain, specify and justify all aspects of the intervention approach which will include
o
o
o
o
the overall framework you are using to guide your thinking (e.g. cognitive,
behavioural….),
the therapeutic techniques you are planning to use (e.g. modelling,
scaffolding….) and
the strategies you expecting the client to ‘take away’ from the therapy
sessions (e.g. mnemonics, requesting help….).
liaison with other professionals, carers and any indirect therapy carried out.
Some students find that because of the nature of their placements, management decisions
have been taken prior to their arrival, and/or local policies require them to adopt a particular
approach where they might have liked to try some alternative. These circumstances do not
preclude you from writing a full and clear rationale. In the first case, you should have access
to assessments carried out prior to your attendance and make sure you understand how
decisions were taken. In the second, you should discuss and the rationale for the approach
adopted within the clinic and for the proposed alternative.
APPENDIX 21
OBJECTIVES FOR THE SPECIFIED EPISODE OF CARE
The episode of care will have been specified in the previous section
Objectives usually refer to the things you intend the client to have achieved by the end of
the episode of care: they represent the intended changes in the client’s behaviour (e.g. “By
the end of the episode of care X will be operating at the 3-word level in structured activities
with minimal prompting.”)
Objectives may be ranked according to the order in which you intend them be achieved and
may be presented in the form of flow charts.
Note that some aspects of the objectives may be more clearly definable than others (for
example, the time-scale for Objective Y may depend on the child’s progress in Objective X).
Your wording should make it clear if this is the case.
In some cases it may be appropriate to set an objective which involves investigation of some
aspect of the client’s performance or behaviour.
METHODS OF GAUGING OUTCOMES
This section should be presented in a succinct format (e.g. bullet points).
The methods of gauging outcomes should map on to your objectives. You may want to
allow some leeway for logging change in behaviours which were not specifically targeted at
the outset.
You will need to be aware of any outcome measures which are required by your particular
Trust (e.g. Teler, Enderby…).
During the course of the episode of care, your monitoring of the effects of therapy may have
indicated that the initial plan, which you explained and justified in the Rationale, needed
significant changes. If this was the case, give a brief explanation here of the changes you
felt were required and the rationale underlying your decision.
REFERENCES (New page)
All citations and assessments should be referenced according to the format outlined in your
Student Handbook.
APPENDICES (New page)
The appendices should be succinct and only contain relevant supplementary information.
Items should be numbered and included in an Index of Appendices. Care should be taken
to remove ALL identifying marks from material in the appendices. Any breach of
confidentiality will affect your mark. You may choose to include:
Reports and letters
These should only be included if they have some very particular
importance.
Transcriptions & test
records
Phonetic transcriptions, linguistic samples, raw data, test
results and extra analyses not presented in the main report if
relevant.
Examples of therapy
programmes used
Include these only where appropriate. If you do include them,
ensure the format is succinct.

Part of the skill of writing reports is an ability to be succinct and avoid
repetition. There is a 4000 word limit.