Case Abstract

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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:

  1. 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.  
  2. 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

  1. Goal one
  2. Goal two
  1. Progress for goal one
  2. Progress for goal two
Recommendations:
  1. first
  2. second
  3. third
Tx - Semester:  (e.g.,  Spring 2000)

 

Goals

Progress

  1. Goal one
  2. Goal two
  1. Progress for goal one
  2. Progress for goal two
Recommendations:
  1. first
  2. second
  3. third