Assess it Before You Report it!

To all my PT, OT, EI, and SLP colleagues:

I just wanted to post a reminder that it is prudent to only report on things that you have either assessed yourself or have observed directly.  I know that I am preaching to the choir, but I had a little incident recently where another clinician on a child's IDT reported that the child has lower extremity hypotonia based solely on the fact that the child was determined to be ineligible for CCS services.

I have worked with this child for over a year now and have felt a catch with quick stretch to her hamstrings and adductors.  I have felt the tightness into straight leg raise, hip internal rotation, and hip abduction.  I have been addressing the occasional scissoring when performing pre-gait and gait activities.  The other therapist only has worked with this child for 2 months and the sessions take place while the child is sitting in a high chair.  How on earth could she write in her report that the child has hypotonia in her lower extremities?  She has not tested it.  She has not observed it.  To me, that is completely irresponsible and doing the child a disservice.

Unfortunately, I am now going to have to call this therapist to discuss our report that is due to Regional Center today in the hopes of coming to an agreement on this child's muscle tone.  I hope that you all will have the courage to charitably open a dialogue with any clinicians with which you have a conflict such as this in the hopes that we can all become better therapists.