Documentation may be an inescapable part of the job, but we are here to make it as simple and efficient as possible!
In this article, we’ll cover how to write an evaluation report for your adult speech therapy patients.
You’ll learn exactly what you need to include, per major funding sources’ requirements (i.e., health insurance companies and U.S. Medicare Part B). Plus, you’ll find a speech report example!
While this article outlines the fundamentals of a speech report, your employer and funding sources may have their own guidelines for documentation. Be sure to follow them!
For pre-made documentation and assessment forms, visit our shop!
More Popular Articles:
- The Complete Guide to Adult Speech Therapy Assessments
- Goal Bank for Adult Speech Therapy
- Swallowing Exercises & Strategies
- Why Do We Write Reports, Anyway?
- What Should A Report Look Like?
- 11 Elements Of A Speech Evaluation Report
- Speech Report Example
- More Resources
Why Do We Write Reports, Anyway?
- To justify the skilled therapy services you recommend (or don’t recommend) and will bill for
- To accurately assess patient progress over time
- To provide a speech therapy assessment for stakeholders to read. These include patients, their families, plus any medical providers down the line from you, including therapists following your plan of care
What Should A Report Look Like?
Every employer’s evaluation report will look different.
Payers, including Medicare and insurance companies, generally don’t care what order you write your report in—as long as you include all of the elements they require.
Below, you’ll find the 11 essential elements of an evaluation report, followed by a speech report example.
11 Elements Of A Speech Evaluation Report
1. Date of Evaluation
Don’t forget to include the date of your assessment!
2. Subjective Information
This is the information you’ll gather by interviewing patients and reviewing medical records.
Subjective Information To Include
- Presenting illness/condition. How does it relate to the medical and treatment diagnoses? Why does the patient need an assessment?
- Date of onset of presenting illness/condition. (e.g., date of CVA, date of fall, date of physician referral)
- Medical history
- Surgical history
- Clinical Tests (CT, X-ray, MBSS, etc)
- Social history
- Living environment
- Previous level of functioning (PLOF). How was the patient’s functioning before the presenting illness/condition? Include reasons for loss of functioning.
- Before CVA, patient was on a regular diet with thin liquids
3. Objective Information
You’ll gather objective data through testing. These include standardized or informal tests, scales, measures, etc.
Objective Information To Include
- Areas to test may include speech, language, swallowing, cognition, voice, resonance, fluency, pain, cranial nerves, adaptive devices, etc.
- Full test name and version, when applicable
- Include the patient’s scores
- Include normal score comparisons
- Include severity levels
- Profound, severe, moderate, mild, borderline, etc.
4. Current Level of Functioning/Evaluation
Your summary of the patient’s current level of functioning is based on the subjective and objective data that you gathered. This will determine whether you recommend treatment or not.
- Include each patient’s strengths and weaknesses
- Include what the patient can no longer do since the presenting illness/condition
- Include how much more assistance they may need since the presenting illness
5. Treatment Diagnosis
Treatment diagnoses are made by you, the therapist, based on your assessment results.
- Speech therapy diagnosis. Mild oropharyngeal dysphagia, severe hypernasality, etc.
- You may add a description of the diagnosis in layman’s terms. A swallowing disorder characterized by…
- You may add examples. The patient said ‘grape’ instead of ‘tomato‘
The prognosis is based on your professional judgment. Rate from excellent, good, fair, to poor.
Your employer may provide guidance on how to determine a prognosis. For example, their documentation system may include descriptions for each prognosis level.
How To Determine Prognosis
- Current level of functioning
- Previous level of functioning
- Date of onset
- Amount of family support (family will help with homework, nurse will monitor health concerns, etc.)
- Insight into deficits
- Any comorbidities and the severity of each
Examples of Prognosis
Patient will likely make a full recovery due to excellent insight and motivation, mild deficits, high previous levels of functioning, and excellent family support
Progress may be limited by poor insights into deficits, ongoing medical issues, the severity of deficits, and minimal support at home.
7. Plan of Care: Patient Goals
Write long-term and short-term goals for your patient, based on the assessment results. Your goals will bridge the gap between the previous and current levels of functioning
- Time frame. When each goal will be reached. Many payers require that you include a time frame
- Long-term goals. Functional goals that can be achieved by discharge from therapy
- Short-term goals. Stepping stones goals that will help your patient achieve their long-term goals. They’re often written to be reached by the next progress report
8. Plan of Care: Therapeutic Intervention
Document what specific therapeutic interventions the treating therapist will use to reach the goals.
- Identify specific speech therapy interventions. Safe swallowing strategies, LSVT Loud, complex problem-solving tasks related to money management, etc.
- Be clear why a skilled speech-language therapy professional is needed for these interventions
- If the goals can be reached with only a home exercise program, for example, payers may deny payment
- Include your recommendations for the duration and frequency of therapy visits. 30-minute sessions, 60-minutes sessions, once per week, three times per week
9. Discharge Plan
If relevant, include where you believe or recommend the patient should discharge to. This is often the patient’s home.
Include how much assistance you believe the patient will need upon discharge.
Discharge Plan Examples
Plan is to discharge to home under supervision of a caregiver
Plan is to discharge to an assisted living facility
10. Coordination With Care Team
Include any relevant communication you’ve had with the care team. Include:
- Communications with your patient’s family or caregiver
- Communications or consultations with other disciplines (nursing, OT, PT, etc.)
- Outside referrals (neurology, otolaryngologist, therapist in a different setting, etc.)
11. Your Signature and Credentials
Make sure that your credentials are legible!
Speech Report Example
Date of Evaluation: 04/19/2022
Subjective Information: Mrs. Jung is a 65-year-old female seen at Local Hospital from 04/10/2022 to 04/17/20200. Mrs. Jung’s daughter, Mei, called 911 after noticing that Mrs. Jung had slurred speech and “wasn’t making any sense.” CT scan performed on 04/10/2022 found that Mrs. Jung experienced a L frontotemporal infarct. She received ST at Local Hospital from 4/11/2022 to 4/17/2022 for dysphagia treatment. A modified barium swallowing study completed during hospitalization found aspiration on cup-sips of thin liquids and moderate pharyngeal residue given soft & bite-sized textures (SLP awaiting full results from Local Hospital medical records). A minced & moist diet with slightly thick liquids was recommended at that time. Mrs. Jung is now referred to ST for continued swallowing concerns to determine risk for aspiration. Mrs. Jung’s medical history is significant for hypertension, hyperlipidemia, and asthma. Surgical history is significant for thyroid removal in ~1999.
Previous Level of Functioning: Patient was previously independent on a regular diet with thin liquids.
Objective Data: The Mann Assessment for Swallowing Ability (MASA) was administered. Mrs. Jung received a 165/200 indicating moderate dysphagia and a mild risk for aspiration given minced & moist textures and mildly thick liquids. Oral periphery examination was completed and significant for moderate bilateral lingual weakness and reduced range of motion, moderately reduced R labial strength and range of motion, and moderately reduced buccal range of motion.
Evaluation: Mrs. Jung demonstrated moderate oropharyngeal dysphagia characterized by reduced mastication, moderate oral residual post swallows, delayed swallows (~2 seconds), reduced pharyngeal elevation, and seemingly protective coughing post swallows given soft & bite-sized textures and thin liquids. She independently cleared some oral residue using lingual sweep technique. Oral residue reduced to minimal given minced & moist textures. Coughing was eliminated given slightly thick liquids. Mrs. Jung reported bolus sensation with soft & bite-sized textures.
Prognosis: Good, given previous success in ST, insight into deficits, high motivation, and stimulability for swallowing strengthening exercises (Mendelsohn Maneuver).
Plan of care (Goals): Long-Term Goal is to safely consume PLOF diet (regular/thin) using safe swallowing strategies IND in 2 months. Short-Term Goals include use of safe swallowing strategies in 100% of opportunities given minimal verbal cues and completion of swallowing strengthening exercises in 4 weeks.
Plan of care (Therapeutic Interventions): Recommend continuation of minced & moist diet and slightly thick liquids at this time to reduce risk for aspiration. Recommend ST 2w6 for skilled dysphagia treatment to provide training in the use of swallowing strengthening exercises and safe swallowing strategies to reduce risk for aspiration and increase Mrs. Jung’s abilities to safely consume the least restrictive diet.
Discharge Plan: Plan is to remain home, possible follow-up modified barium swallowing study within the next month.
Signature & Credentials: Ana Garcia, M.S., CCC-SLP
See what speech-language pathologists are saying about The Adult Speech Therapy Starter Pack!
- American Physical Therapy Association. (2021). Elements of Documentation Within the Patient/Client Management Model. Retrieved September 21, 2021 from https://www.apta.org/yourpractice/documentation/defensible-documentation/elements-within-the-patientclient-managementmodel
- American Speech-Language-Hearing Association. (2021). Documentation in Health Care. Retrieved September 13, 2021, from www.asha.org/Practice-Portal/Professional-Issues/Documentation-in-Health-Care/
- American Speech-Language-Hearing Association. (2021). Examples of Documentation of Skilled and Unskilled Care for Medicare Beneficiaries. Retrieved September 13, 2021, from https://www.asha.org/practice/reimbursement/medicare/examples-of-documentation-of-skilledand-unskilled-care-for-medicare-beneficiaries/#skilled-unskilled
- Gawenda, R. (n.d.) Documentation: Everything After the Evaluation Until Discharge. [Online lecture]. MedBridge Education. https://www.medbridgeeducation.com/courses/details/documentationeverything-after-evaluation-until-discharge-rick-gawenda
- Gawenda, R. (n.d.). Documentation for Evaluations and Re-Evaluations [Online lecture]. MedBridge Education. https://www.medbridgeeducation.com/courses/details/documentation-evaluations-reevaluations-rick-gawenda
- Medical Learning Network, The. (2019). Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements [PDF file]. Retrieved on September 13, 2021, from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/OutptRehabTherapy-Booklet-MLN905365.pdf