The MED-EL Client Diary · Measles ¡ Mastoiditis ¡ Mumps ¡ Meningitis ¡ Otosclerosis ¡ TORCH Group of Infections ¡ ... concerns that would guide in structuring the counseling

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The MED-EL Client Diary


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Name

Clinic Name

This folder is aimed at providing formats for the systematic

documentation of basic client information, evaluation reports and

habilitation progress statement. It can be maintained by the concerned

habilitation professionals, at the habilitation clinics. For the purpose of

quick reference the folder is divided into various sections.

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CONTENTS

1. Client Background Information

1.1 Client Background Information

2. Pre-Operative Evaluation Reports

2.1 Medical Evaluation

2.2 Audiological Evaluation

2.3 Modified ChIP

3. Implantation Details

3.1 Implant Details

3.2 First Fitting

3.3 Mapping Details

3.4 Service Record

3.5 Service Logistics

4. Habilitation

4.1 Therapy Enrollment Form

4.2 Lesson Plan Format

4.3 Auditory Progress Monitor

5. Assessments

5.1 Consultants Notes

5.2 Parent’s Diary

6. Miscellaneous

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Demographic Data

Name

Male ¡ Female ¡ Age Date of Birth

Permanent Address

Phone Number Mobile E-Mail

Medical History

Significant Pre/ Peri/ Post Natal History

Developmental History

Self Help Skills Normal ¡ Delayed ¡

Gross and Fine Motor Milestones Normal ¡ Delayed ¡

Cognitive Skills Normal ¡ Delayed ¡

Speech and Language Milestones Normal ¡ Delayed ¡

Mode of Communication (Verbal/Non-Verbal)

Receptive skills Gestural ¡ Verbal ¡ Sign Language ¡ Mix of Spoken Words and Signs ¡

Others ¡ Please specifiy:

Expressive skills Crying ¡ Meaningful Vocalization ¡ Babbling ¡ Words ¡ Phrases ¡

Sentences ¡ Others ¡ Please specifiy:


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Details on Hearing Loss

Age of Identification of Hearing Loss

Cause of Hearing Loss

Degree of Hearing Loss

Type of Hearing Loss

Causes of Hearing Loss

Congenital ¡Hereditary ¡Viral ¡Trauma ¡Ototoxicity ¡ Meningitis+Ototoxicity ¡

Measles ¡ Mastoiditis ¡ Mumps ¡ Meningitis ¡ Otosclerosis ¡ TORCH Group of Infections ¡

Unknown ¡ Others ¡ Please specifiy:

Hearing Aid Use

Right Ear Left Ear Bilateral

Age of HA Fitting

No of Years of Consistent HA Use

Details on the Usefulness with the HA

Cochlear Implant Use

Right Ear Left Ear Bilateral

Age of CI Fitting

No. of Years of CI Use

Details on the Usefulness with the CI


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Immunizations

Reports Enclosed

1) Hib

2) Pneumococcal

Recommendations

2.1 Medical Evaluations

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PTA

Aided Audiogram

Speech Audiometry

Impedance

OAE

BSERA/ASSR

Other Relevant Reports

ENT Evaluation

Radiological Evaluation

CT Scan

MRI

Comments

(Reports to be enclosed)

2.2 Audiological Evaluation

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Here the CI team using Chip, sketch out the profile of the to-be implanted or implanted

child, from their individual view point. In the end of profiling, the team outlines their

concerns that would guide in structuring the counseling and future action. The guidelines

for using ChiP – Modified is provided in the Appendix.

Cochlear Implant Program - Children’s Implant Profile (ChIP - modified)

Date of Team Review Date (s) of Evaluations

Etiology of Hearing loss Age at Onset of Hearing Loss

Communication Mode School Placement

TEAM IMPRESSIONS OF THE FACTORS IMPORTANT TO IMPLANT USE AND SUCCESS

NO CONCERN SOME CONCERN GREAT CONCERN

1. OTOLARYNGOLOGY

Medical Evaluation/Physician Concerns

Radiological

2. AUDIOLOGY

Test Reliability

Attention/Behavior

Hearing Aid Use

Compliance with Recommendations

Hearing Aid Benefit

Auditory Skills

(Given CA and Duration of Deafness)

Other Disabilities

3. SPEECH PATHOLOGY

Receptive Language

Expressive Language

Play/Social Skills

Oral Motor Skills

Speech Reading Skills

Communicative Intent

2.3 Modified ChIP Assessment Form(Children’s Implant Profile)

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TEAM IMPRESSIONS OF THE FACTORS IMPORTANT TO IMPLANT USE AND SUCCESS (Cont.)


3. SPEECH PATHOLOGY (Cont.)

Speech Production

Attention/Behavior

Chronological Age/Duration of Deafness

Other Disabilities

4. SOCIAL WORK

Family Structure & Support

Attention/Behavior

Expectations (Parent/Child)

Other Disabilities

5. EDUCATION

Current Educational Placement

Class Conducive to Implant Use

Availability of Support Services

Appropriateness of Skills of Service

Educational Staff CI Training

Future Placement

Parent’s Ability to Participate

in Education Process

Child’s Ability to Participate

in Education Process

Notes


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Team Concerns

Recommendations

Date Discussed with Family

Cochlear Implant Team Member Signature Cochlear Implant Team Member Name (PRINT)

Courtesy : Ms MaryKay Therres, The Children Hospital, Philadelphia


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FACTORS IMPORTANT TO IMPLANT USE & SUCCESS


1. OTOLARYNGOLOGY

Medical Seizure or reactive airway disorders. Past history of meningitis.

Airway disorder or cardiac issuesNo pneumococcal vaccination.

Radiological Cochleas are normal & patent; normal facial nerve course.No concerns for absent eighth nerve.

Cochlea partially ossified or not completely formed. Hypoplastic eighth nerve or IAC, or concerns about eighth nerve status. Some abnormality of facial nerve course.

Absent eighth nerve. Very aberrant facial nerve. Cochlea completely ossified or severely malformed.

2. AUDIOLOGY

Test Reliability Good test reliability. Fair test reliability. Poor test reliability/CNT

Attention/behavior Age-appropriate ability to complete tests.

Requires two or more sessions for complete test battery.

Could not test –with 2 testers and lots of toys.

Hearing aid useCompliance and recommendations

History of consistent hearing aid use.

Limited hearing aid use (> 50%).

No history of consistent use (< 50%); No hearing aids.

Compliance and recommendations

Consistent appointments & and follow through - documentation provided/available.

Frequent cancellations of appointments.

No follow-up or large gaps in audiologic service; frequent no shows.

Hearing aid benefit Little or no functional hearing aid benefit.

Some functional hearing aid benefit.

Does not meet FDA guidelines for candidacy.

Auditory skills (given ca & duration of deafness)

Appropriate for age duration of deafness.

Some basic pattern perception skills.

Could not demonstrate consistent detection; Sound not assoc. w/meaning.

Other disabilities No other conditions. Limited head control and eye contact.

Significant physical delays; significant self-stimulation.

2.4 Modified ChIP Guidelines – Rev. 06/06

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3. SPEECH PATHOLOGY

Receptive language Developed skills appropriate to exposure to communication mode.

Slow to develop or delayed skills; demonstrates some.

Skills delayed significantly or not developed.

Expressive language Developed skills appropriate to exposure to communication mode.

Slow to develop or delayed skills; demonstrates some.

Skills delayed significantly or not developed.

Play/social skills Appropriate for age. Under 2 y: <6 m. delay; Over 2 y: moderately delayed.

Under 2 y: >6 m. delay; Over 2 y: significantly delayed.

Oral motor skills Oral motor issues observed.

Drooling/low tone; able to imitate some gross & fine movements.

Much difficulty imitating gross movements.

Speech reading skills Has developed. Uses moderately. Minimal to no use of speech reading.

Communicative intent Age appropriate. Mixture of initiated and imitative language.

Only imitative; no to minimal spontaneous production.

Speech production Appropriate for hearing and exposure.

Moderately delayed; difficulty imitating sounds

No imitation to severe difficulty.

Attention/behavior Age appropriate. Moderate focus and some behavior issues with fair parent management.

Focus and attention issues with poor parent management.

Chronological age/duration of deafness

0 – 2 years old or years of deafness.

2 to 4 years old or years of deafness.

Over 4 years old or years of deafness.

Other disabilities Does not affect ability to develop auditory or oral skills.

Will moderately affect ability to develop auditory oral skills.

Will significantly affect auditory oral skill development.


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4. SOCIAL WORK

Family structure & support Family communicates with child effectively; actively involved in child’s therapy & educational program; effectively coping with parental stress.

Some family members communicate with child effectively; moderate parental stress; occasional canceled or broken appt. during eval or by history.

Family does not communicate with child effectively; non-intact family with issues that override child’s needs; severe parental stress; past history of noncompliance with medical regimens.

Attention/behavior Behavior problems typical for age; effective parental control of behavior.

Sporadic parental control of child’s behavior; inconsistent engagement in therapy sessions.

Severely hyperactive, aggressive or defiant behavior; poor parental control of child’s behavior; consistent disengagement in therapy sessions.

Expectations (parents/child)

Realizes CI will not restore normal hearing; parental agreement about implant; family has plan for rehabilitation.

Believe child will move to a mainstream setting with no support services; expectations are inflexible; reliability.

Believe CI will restore normal hearing; family has no plan for rehab.

Other disabilities No other conditions. Limited head control and eye contact.

Significant physical delays; significant self-stimulation.

5. EDUCATION

Current educational placement

Certified staff; strong auditory oral; good language environment; stable school; appropriate educational curriculum.

TC with less than strong auditory oral emphasis; mixed categorical placement, daycare; teacher not certified DHH; weak curriculum and poor school standards.

Voice off environment with little encouragement to use voice or practice auditory oral skills; curriculum does not address hearing loss history of noncompliance with medical regimens.

Class conducive to implant use

Good acoustic environment; small student to teacher ratio.

Less than ideal listening environment; more than eight students in class.

Noisy environment; large class with variety of disorders.


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5. EDUCATION

Availability of support services (ie: slp, hearing therapist, educational audiologist).

Well trained and available support staff as employees or contracted providing sufficient level of service; have strong administrative support.

Insufficient number of trained staff to provide services; frequent staff changes; administrative support willing to send staff for training or to hire new staff.

Very limited or no trained/certified support staff to provide services; no administrative support for change.

Appropriateness of skills of service.

Well trained staff and have experience with children who have a CI.

Have limited experience, training or knowledge about CIs.

Have no experience with children with hearing aids or CIs.

Educational staff ci training.

Classroom and support staff have attended CI workshops or specialized trainings; regularly attend trainings; certified DHH as lead teacher or primary educational support experienced with CIs.

Staff isolated from training areas; staff interested in obtaining training; educational staff without DHH degree and limited access to support. form trained staff

No trained CI staff and no plan to do so; staff and school policy resistant to CI use.

Future educational placement.

Certified staff; strong auditory oral; good language environment; stable school; appropriate educational curriculum.

TC with less than strong auditory oral emphasis; mixed categorical placement, daycare; teacher not certified DHH; weak curriculum and poor school standards.

Voice off environment with little encouragement to use voice or practice auditory oral skills; curriculum does not address hearing loss.

Parent’s ability to participate in education process and provide a good learning environment at home.

Understand educational law and is well informed about many issues related to deafness, education and CIs; strong advocacy skills; home is a positive communication environment.

Parent has beginning knowledge of educational issues, deafness and communication options; needs support to get information; home ha the potential to be a good learning and listening environment; potential for advocacy skills.

Parent has little understanding of educational issues affecting child; other issues are effecting their ability to follow through with necessary procedures to become better informed; home is not a positive learning or communication environment.

Child’s ability to participate in education process.

Normal developmental milestones except for the area of hearing; shows a strong interest in communicating.

Child may have other developmental issues that could impact benefit from implant.

Child has severe developmental issues; unlikely implant would make an educational difference.

Courtesy : Ms. Marykay Therres, The Children Hospital, Philadelphia


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RIGHT EAR LEFT EAR

Date of Surgery Date of Surgery

Implant Serial No. Implant Serial No.

Date of Switch On Date of Switch On

Processor Serial No. Processor Serial No.

Coil Serial No. Coil Serial No.

Fine Tuner Serial No. (OPUS 2) Fine Tuner Serial No. (OPUS 2)

3.1 Implantation Details

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Date of Switch On

Test Administered /Scores

Ling Sounds

Spondee

PB Words

simple Questions

Comments

3.2 First Fitting

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Mapping Date Remarks Due Date

3.3 Mapping Record

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Date Complaint Remedial Action By Follow Up Parent Taken (If Required) Signature

3.4 Service Record

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Date Service No. Details Closing Details

3.5 Service Logistics

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Name M/F

Date of Birth Implant Age

Parent Name Occupation

Permanent Address

Phone Number Mobile Email:

DETAILS ON IMPLANTATION

Date of CI Surgery Surgeon Hospital Name

Right (Y/N) Implant Processor

Left (Y/N) Implant Processor

Bilateral

Date of Switch On

Speech Processing Strategy Used

DETAILS ON HABILITATION

Date of Enrollment for Therapy Clinics

Therapy Approach

(Primarily Auditory/Primarily Auditory Visual/Primarily Gestural/Multisensory Approach/ Others Specify)

Schooling (NA/Preschool/Special/Mainstream/Others) Details Specify:

Mother Tongue:

Language

Spoken: Written: Read:

Signature of the Clinical In-Charge

NAME

4.1 Therapy Enrolment Form

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Listening Check

/a/ /i/ /u/ /s/ /sh/ /m/

Detection

Identification

No Sound (CATCH TRIAL)

Lesson Plan Duration Of Plan

Goals Remarks/Notes

Audition

Language

Expressive Language

Speech Sounds

Other Client Specific Goals

Music Goals

Clinician

4.2 Lesson Plan Format

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Auditory Goals Date of Mastery (90%)


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Level 5B: Processing/Comprehension

6. Answer complex questions

7. Listen to longer paragraphs and answer complex questions

8. Sequence with/without visual support

9. Increase cognitive language skills

10. Follow conversation with familiar topics

11. Follow open ended conversation

Level 5A: Processing/Comprehension

1. Advanced vocabulary development

2. Increase auditory word-play association

3. Answer simple questions

4. Understand sentence containing details and elements

5. Answer simple questions about short paragraphs

Level 4: Identification

1. One key word in context with/ without suprasegmentals

2. Two key words in context

3. Three key words in context

4. Four+ key words in context

Level 3: Segmental - Association/Identification

1. Speech sound difference in isolation

2. Vowel and consonant difference in same length words

3. Vowel only difference in words

4. Consonant only difference in words

Level 2: Suprasegmental - Discrimination/Association

1. Speech

2. Onomatopoeic

3. Word length

4. Sentence length

5. Intensity/pitch

6. Oral

7. Prosody

Level 1: Awareness

1. Voice

2. Environmental

3. Ling’s

4. Voice

Acknowledgement: Leo De Raeve – ONICI Belgium


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The CI habilitation is a team approach. Pages are provided for regular interaction between professionals

to speed up the follow up process.

5.1 Consultant’s Notes- Team Interaction Page

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Consultant Name Date

Notes for other Members



5.1 Consultants’ Notes

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5.2 Parent’s Diary

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6. Miscellaneous

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6. Miscellaneous

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6. Miscellaneous

Documents

The MED-EL Client Diary · Measles ¡ Mastoiditis ¡ Mumps ¡ Meningitis ¡ Otosclerosis ¡ TORCH Group of Infections ¡ ... concerns that would guide in structuring the counseling