Understanding therapy reports

blog medical reports therapy Mar 16, 2021
Understanding medical and therapy reports

At the start of every school year, paperwork abounds. Children who are coming into your class with a diagnosis or who attend a therapy session either with an Occupational Therapist, Speech Pathologist, Psychologist, Paediatrician, Physiotherapist or other health-related therapist will often have the relevant reports already on the school file. If they are new to your school, the necessary reports and information will be provided by the child’s prior school or parent.

These reports provide valuable information that will assist in preparing your student for success in your class. If written well, the reports contain recommendations that will help make the transition into your class easier for you and them. Between us, some of these reports are really, really long and, unless you have that particular qualification, you won’t understand most of the jargon used. I can remember once reading in my daughter’s report card in year 2 that she was “ so we are all guilty of dazzling with our brilliance.

The structure of a medical or allied health report usually follows a similar format.

Identification

A child’s identification details such as name, date of birth, address, parents’ names and diagnosis or medical condition. Also included, is the date of the assessment and the date of the report.

Background information

Next, there will be some background information about why the child was referred to that health professional, the child’s development, if there have been any significant issues or situations in the child’s life, family structure and presenting concerns. This is a helpful section to pay attention to as it can provide you with a holistic view of the child’s struggles and supports beyond their school life. 

Assessment findings

The report will then move into the assessment findings. Here, it will make comments about where the assessment was conducted, what assessments were completed, how the assessment went and it will report the detailed assessment findings. This is the part where the jargon can get a little overwhelming and often we skim read so we can reach the recommendations at the end. I understand. However, the assessment findings can provide you with crucial insights into specific areas of a child’s  A well-written report will clearly interpret what the assessment findings mean in practical terms so that anyone can understand it.

Recommendations

The recommendations section is often the star of the report. This is where we can see how the findings of the assessment can be translated into practical strategies that can be adapted for the classroom. Try not to feel overwhelmed when reading the recommendations – sometimes there can be so many. The therapist or health professional should (hopefully they do), highlight the highest priority recommendation. If they did, start there. If they didn’t, then speak to the child’s parent about what they would like to see implemented in the classroom and, with their input, you can decide on what will work in your classroom. If you try to do it all you will become so overwhelmed nothing will be implemented or you will try to do it all and nothing will stick, and you will become overwhelmed again. Either way, prevent overwhelm by choosing a recommendation and trial that one recommendation for a few weeks before adding in another.

If you want to know more about the findings of the assessment, where to access the resources recommended or even how to better understand the presenting condition or diagnosis, it is important that (with parent consent) you contact the therapist and ask them any questions you have. Most therapists and health professionals are more than happy to help, particularly if the report is recent and was designed to assist with the child’s smooth transition into a new class or school. Supporting the child and their needs are at the centre of any collaborative approach. And the best way we can help is by communicating effectively with each other to better understand the needs and strengths of the child we are working with. 

 

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