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Oral Speech Screening

This document summarizes a speech therapy screening for a patient. It includes information about the date, patient details, reason for screening, prior level of function, areas screened and deficits noted. It also provides the results of oral motor, dysphagia, cognition and language screenings. The therapist recommends a speech therapy evaluation is needed and signs off with their signature and date.

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Nabed Alhaya
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107 views2 pages

Oral Speech Screening

This document summarizes a speech therapy screening for a patient. It includes information about the date, patient details, reason for screening, prior level of function, areas screened and deficits noted. It also provides the results of oral motor, dysphagia, cognition and language screenings. The therapist recommends a speech therapy evaluation is needed and signs off with their signature and date.

Uploaded by

Nabed Alhaya
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Speech Therapy Screening

Date of Screening:________________ Patient Name: ______________________________ Date of Birth: _______ Room #: ________________ Facility: ______________________________ Admit/Readmit Date: _______ DOB: __________________ Physician: ______________________________ Current Diet: ___________________________________ Prior Level of Function:__________________________________________________________________ Reason for Screen:___ Routine Staffing ___New Admit/Readmit ___Nursing/Family/Staff Referral ___Incident Report ___Restorative Programs ___Other:______________________________________ Prior Speech Therapy? ___Yes ___No Last D/C Date:_______ Level @ D/C from Therapy:____________ Functional Areas Screened
S=Screened D=Deficit

S ___ ___ ___ ___ ___ ___ ___ ___ ___

D ___Speech intelligibility ___Vocal weakness ___Confrontational naming ___Automatic speech ___Answering questions ___ Auditory comprehension ___Simple conversation ___Oral motor movements ___Swallowing

___ ___ ___ ___ ___ ___ ___ ___ ___

S D ___ Memory/ recall ___ Orientation ___ Problem-solving/ Safety awareness ___Attention ___ Repetition ___ Following directions ___Complex conversation ___Weight Loss ___Dehydration

Problems/Declines Noted:________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

___Speech/Language therapy evaluation is recommended ___Speech/Language therapy evaluation is not recommended Why Not?: _________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

______________________________________________________________________________________ Therapist Signature/ Credentials Date

Oral Motor Screening Protrude tongue Puh, Puh

Lateralize tongue to corners Tuh, Tuh

Lip pucker Kuh, kuh

Say AH Smile Puh, tuh, kuh

Dysphagia Screening Administer 1 teaspoon (5cc) amounts of thin liquid and pureed consistencies; of a cracker or cookie as appropriate and observe for the following: Yes No Yes No Breathing difficulties Poor awareness & control of secretions Pocketing of material/residue Reduced laryngeal elevation Coughing before, during, and/or after Significant fatigue Increased oral or laryngeal secretions Throat clearing Multiple swallow per bolus(piecemeal Vocal quality changes (wet, gurgly) deglutition) Cognition & Language Screening: Orientation to Time & Place Date DOW Month Year

Season of the year

Place/ Facility

Room

City

State

County

Converational Speech Tell me what kind of work you have done in the past Immediate Recall (Say all 3 words slowly & clearly then as client to repeat them) ball flag tree Attention (Ask client to begin with 100 and count backwards by 7. Stop after 5 subtractions. ) 93 86 79 72 65 Spell WORLD backwards D L R O W Delayed Verbal Recall (Ask client to recall the 3 words from earlier) ball flag tree Confrontational Naming (Present object and ask What is this called?) Pen Hand Pillow Door Ceiling Automatic Speech Count to ten Tell me the days of the week Sentence Completion ( Finish these sentences for me.) Three strikes and youre I pledge allegiance to the As you leave, close the For fresh air, you raise the Repetition ( Repeat these words.) book home spice scarecrow The silver moon hung in the dark sky tornado The phone is off the

administration

under the old wooden bridge

Yes/No Questions ( Im going to ask some questions, just tell me yes or no) Is your name Johnson? Is your name_____? Do you live in Rhode Island? Am I touching my eye (touch nose)? Do you wear a glove on your foot? Is a chicken bigger tan a spider? Do you put your shoe on before your sock? Following Directions Point to your nose Open your mouth Point to the floor, then point to your nose With your left hand point to your right eye Before opening your mouth, touch your ear

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