Initial Evaluation (ST) - Fincham, Jackson 04/13/2021 - Colvin, Bailey

Fincham, Jackson

Gender: M Time In / Out: 02:30 pm - 03:30 pm

Date: 04/03/2021 DOB: 01/31/2018
Address: 117 Oakview Street Provider: Community-STARs
City, ST ZIP: Culpeper VA 22701 Location: Community-STARs - 11
Contact Person: Self Physician: Pappas, Diane, MD
Payer ID #: 2004849201 Treating Therapist: Colvin, Bailey
Start of Care Date: 01/29/2020 Plan of Care 04/12/2021 - 10/12/2021
Effective:
Reviewer: Engel, Michelle - M.A, CCC-SLP

Diagnoses: ICD 10

Code Onset Diagnosis

F80.9 - Developmental disorder of speech and language, unspecified

R62.0 - Delayed milestone in childhood

P94.2 - Congenital hypotonia

F88 - Other disorders of psychological development

P07.24 - Extreme immaturity of newborn, gestational age 25 completed weeks

P07.01 - Extremely low birth weight newborn, less than 500 grams

Patient History

Medical History: Jackson was born at 25 weeks gestation weighing 14.5 ounces. He spent 230 days in the NICU,
diagnosed with IUGR and severe BPD. Jackson had a trach with a ventilator. He was weaned off the
ventilator and his trach was plugged. Jackson had a Passy-Muir valve, but has since been successfully
decannulated as of 3/15/2021. Jackson has had a G-tube since 8/17/2018. Jackson now uses his G-tube
for supplemental nutrition, but also consumes food orally. Mother reported that she uses a pipette to
provide Jackson with liquids
Treatment History: Jackson has received ST services previously through early intervention. He also has a history of speech
therapy at C-STARs pediatric therapy clinic.

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Initial Evaluation (ST) - Fincham, Jackson 04/13/2021 - Colvin, Bailey

Chief Complaint / Parents expressed concerns in both Jackson's receptive and expressive language skills. Jackson's mother
Expectation: would like Jackson to be able to express himself.
Surgical History: Jackson underwent tracheostomy surgery on 5/31/2018, G-tube and hernia surgery on 8/17/2018 and
atrial septal defect surgery on 9/17/2018. He has a procedure scheduled for 4/30/2021 for a tracheostomy
stoma closure.

Communication: General Communication

Comments:

Jackson was not able to undergo formal standardized testing due to decreased intelligibility of speech and scattered joint attention.
Rather, his communicative behaviors and articulation were observed and compared to age-level norms to determine his level of
development(criterion-referenced). The clinician used questions from the Receptive Expressive Emergent Language Test- 3 in order
collect parent's report of Jackson's Receptive and Expressive language skills. When compared to age level norms, Jackson's
receptive language skills were similar to those of an 18 month old, and his expressive language to a 12 month old. The clinician also
used observation in play to informally assess Jackson's current level of functioning.

PLAY- During play, Jackson played functionally with few toys, often banging them together or throwing them. Mother reported that
this was typical of Jackson's play skills in the home setting. Parent reported that he does not make animal noises or environmental
sounds like truck noises at home. Jackson demonstrated fleeting attention skills throughout the majority of the session. He seemed to
enjoy popping bubbles and playing with trucks.

RECEPTIVE- Jackson demonstrated understanding of simple commands during play. Parent reported that he follows 1 and 2 step
directions at home, such as take your clothes off and get into the tub or pick up the ball and give it to me. His responses to ST's
directives and play conversation were appropriate, based on his actions and from what could be understood. Mother reported that
Jackson is not able to pick out objects from a group of 5 and does not take turns in conversation when babbling.

EXPRESSIVE- Jackson produced mostly approximations of single words after his mother requested for him to speak. For example,
Jackson's mother said "Jackson, say please.", and Jackson answered with "diddle". Mother reported that this is his word for please.
Jackson also produced "mama", "nana" "lala" and "gaga" for family members names after prompted. Jackson will frequently use signs
when asked to, including signs for help, more, thank you, up, eat, and drink. In this session, Jackson did not use signs or
verbalizations spontaneously for communicative purposes. In today's session, Jackson verbalized "buh" for bubble and produced an
approximation for thank you when verbally prompted. Mother reported that when Jackson wants an item, he often points and
vocalizes with a grunt, which he demonstrated many times during today's session. Jackson does not indicate when he needs a diaper
change.

ARTICULATION- Jackson produced the following sounds when verbally prompted this session: /p, b, d, n, m, g/. He produced these
sounds in CV and CVCV words. Jackson's mother reported that Jackson does not often communicate spontaneously with
consonants, but enjoys producing vowel sounds when playing or singing, such as "ooh" and "aww". During spontaneous vocalizations
this session, air could be heard escaping through Jackson's stoma, which only mildly affected intensity of speech sounds.

ORAL-MOTOR- A formal oral motor exam was not conducted. Jackson was observed to have an open-mouth posture throughout the
evaluation, which his mother confirmed was typical. Jackson often drinks liquid through a pipette, but sometimes drinks from a cup.
When drinking from a cup, Jackson does not close this lips around the cup. Leakage is reported when drinking liquids. Parent
reported that Jackson has deficits in creating suction due to his stoma, but doctors seem confident his suction abilities will increase
upon closure of the stoma.

Strengths

Repeats some sounds and words

Follows one-step directions
Supportive parents seeking intervention
Adequate social skills

Summary

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Initial Evaluation (ST) - Fincham, Jackson 04/13/2021 - Colvin, Bailey

Jackson demonstrated below age level performance in receptive language, expressive language, and attentional/play skills requiring
the need for skilled ST intervention.

Goals

Long-Term Goal: (Started on 04/13/2021)

Jackson will imitate bilabial sounds /p, b, m/ in isolation or in syllables 5x per session in 5 sessions with prompts and cues as needed.

Long-Term Goal: (Started on 04/13/2021)

Jackson will comment or label spontaneously or after clinician model 3x per session in 4 sessions.

Long-Term Goal: (Started on 04/13/2021)

Jackson will use signs, words, or word approximations to make a request, with models and prompts as needed, 3 times per session in
5 sessions

Long-Term Goal: (Started on 04/13/2021)

Jackson will imitate exclamations, animal noises or noises in play, (such as uh-oh, oops, vroom, moo) 3x per session in 3 sessions
with prompts and cues to fade.

Long-Term Goal: (Started on 04/13/2021)

Jackson will follow directions containing actions or prepositions in 75% of trials with prompts and cues to fade.

Planned Interventions

Billing Codes

Code Description

99072 Cleaning and PPE to support safe in-person visits

92507 Speech / Hearing Therapy

92523 Speech Sound Language Comprehension

Frequency / Duration

Visit Frequency 2x/Week

Therapy Duration 6 Months

Effective Range (Plan of Care) 04/12/2021 - 10/12/2021

Intervention Comments
Goals are written to be met within 6 months with new goals to be added as needed. At that time, Jackson will be re-assessed to
determine progress and update goals.

Signatures

Certification of Medical Necessity: It will be understood that the treatment plan stated above is certified medically necessary by the
treating clinician and physician mentioned in this document. Unless the physician indicates otherwise through written correspondence
with our office, all further prescriptions will act as a certification of medical necessity on the treatment plan indicated above.

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Initial Evaluation (ST) - Fincham, Jackson 04/13/2021 - Colvin, Bailey

Electronically Electronically
Signed On: Signed On:
04/03/2021 08:48 04/04/2021 02:34
am pm

Therapist: Colvin, Bailey Reviewer: Engel, Michelle - M.A, CCC-SLP

State License #: 2202008652

Date:

Physician: Pappas, Diane - MD

NPI: 1548339179

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