Case Abstract

The purpose of the case abstract is to ensure the best of care for each of our clients. By carefully, thoroughly, and thoughtfully reviewing each case we will give our patients the best possible treatment. While our intentions are to focus on our clients and their histories, this process will sometimes have unintended results, such as provoking us to wonder about the decisions made by previous clinicians and supervisors. These situations provide us with two learning opportunities:
- We can attempt to see the case from another perspective, specifically that of a previous clinician and supervisor, and see how that might inform our work on the case.
- We can learn the importance of attending to the whole case at the beginning of each and every treatment period and use the complete case to plan our treatment..
Once you have completed this form, put a printed copy of the form without identifying information in your client's lesson plan folder and keep it there.
| Clinician: |
___________________________________________________________________ |
| Client (initials) |
___________________________________________________________________ |
| Client Birthdate: |
___________________________________________________________________ |
| Client Chronological Age: |
___________________________________________________________________ |
| Date of Abstract: |
___________________________________________________________________ | |
Dx (initial): (insert date of initial dx)
Summarize tests and results in chart form.
|
Test |
Results |
| GFTA |
Errors: t/k d/g etc. | |
| Tx - Semester: (e.g., Fall 1999)
|
Goals |
Progress |
- Goal one
- Goal two
|
- Progress for goal one
- Progress for goal two
|
Recommendations:
- first
- second
- third
| |
| Tx - Semester: (e.g., Spring 2000)
|
Goals |
Progress |
- Goal one
- Goal two
|
- Progress for goal one
- Progress for goal two
|
Recommendations:
- first
- second
- third
| |
|