Speech Therapy Documentation in 9 Steps!

There’s no doubt that the look of documentation varies a lot! Some documentation systems have checkboxes and SmartPhrases. While others read like essays.

But whatever the look, documentation always has the same goal: Convey information about a patient’s speech therapy journey in a way that justifies your actions and gets your agency paid.

In this post, you’ll learn the 9 steps of adult speech therapy documentation. These are the baseline pieces of information that most payers need to see to pay for your services.

Will your facility and state layer on extra standards? Probably. So know and follow their guidelines.

But if fear or perfectionism drives you to write 1/2-page narratives in your SOAP note, this post is for you.

Or, if you figure that just checking boxes and copying and pasting the plan of care will fly, this post is also for you!

Keep scrolling for the 9 steps. And for documentation and assessment templates, visit our shop!

More Documentation Help!

• How to Write a SOAP Note
• How to Write an Evaluation Report
• Goal Bank for Adult Speech Therapy

The Adult Speech Therapy Roadmap

Speech therapy has a predictable flow. No matter the disorder, you can follow the same basic route, from chart review to discharge.

We call this flow The Adult Speech Therapy Roadmap. And we created it for adult SLPs because having a route to follow is much more efficient than the alternative—both for you and your patients!

In this post, we’ll cover just one part of The Roadmap: The 9 steps of speech therapy documentation.

What All Documentation Should Include

Everything you document, from evaluation reports to SOAP notes, should show that any action you take in your role as a speech therapy professional (is):

• Medically necessary
• Requires the skills of a speech therapy professional
• Functional (or will lead to a functional goal)
• Adds value to the patient’s health
• A specific and effective treatment/choice for the patient’s condition

9 Steps of Speech Therapy Documentation

1. The Date

This is a pretty easy one!

Include the date of the initial evaluation, the reporting period for a progress report (e.g. date of evaluation to most recent treatment date), the date of treatment for a treatment note, and the reporting period for a discharge report.

For reports, you may also need to include the date your report was written.

For treatment notes, know your facility’s guidelines on how to document treatment time. A common way is to document the total treatment time of any timed codes you bill for that session.

2. Diagnoses

On reports, you’ll include both the patient’s medical and speech therapy diagnoses.

3. Previous Level of Functioning (PLOF) or Previous Status

This is your patient’s status “before,” which is important so that you can compare it to your patient’s “now.”

In your initial evaluation, the PLOF is the patient’s status before the qualifying event. Be sure to include the reasons for any loss of functioning.

For all other documentation, the previous status will help show if speech therapy is helping and to what extent.

PLOF Example
Before CVA, patient was on a regular diet with thin liquids.

PROGRESS & DISCHARGE REPORTS

For these reports, the previous status is the patient’s progress toward goals at the beginning of the reporting period. Include objective information to more accurately measure progress. These are the standardized test scores, measurements, and any other relevant data from the previous progress report (or the initial eval if it’s the first progress report).

TREATMENT NOTES

For an individual treatment note, you usually don’t explicitly state the patient’s previous status. But it’s implied to the reader of the note in your ongoing assessment of their progress toward their goals—or by reading previous notes!

Examples
Patient’s accuracy has steadily improved the past 3 sessions.

Patient did not progress towards their goals this session, likely due to fatigue related to dialysis.

4. Current Level of Functioning (CLOF)

The CLOF is the patient’s “now.” This is important so that you can compare it to their “before” (previous level of functioning or status). How has their status changed because of speech therapy treatment or their qualifying event (e.g. stroke)?

INITIAL EVALUATIONS

In the initial evaluation, the CLOF is your summary of the patient’s status now.

You’ll decide this based on the subjective and objective data that you gathered during your assessment and chart review. The CLOF will help you determine whether you recommend treatment or not.

Your initial evaluation will also paint the picture of the patient’s medical journey from their PLOF to CLOF. Read How To Write An Evaluation Report for a step-by-step guide.

PROGRESS & DISCHARGE REPORTS

In progress and discharge reports, the CLOF is your summary of the patient’s progress toward their goals during the reporting period. The aim is to show if and how much your skilled speech therapy services have helped your patient.

In this section, include:

1. A summary of the patient’s progress toward their goals
2. A summary of the patient’s response to treatment
3. Whether they met each goal or not. If not, explain why
4. Objective tests, measurements, and data
5. Patient/caregiver’s reports
6. Successful interventions. List the tasks/activities, strategies, cues, etc. that helped the patient improve

TREATMENT NOTES

Much of your treatment notes will be spent documenting the patient’s CLOF during that session. Include:

It is key that your treatment note justifies that the unique skills of a speech therapy professional were required during the session. Every task and cue you choose should:

1. Logically move your patient toward their goal
2. Be skilled

Not skilled: “Conversation practice” will not cut it. A spouse or volunteer can do that!

Skilled: “Phrase-level expressive language treatment by having patient pair nouns with appropriate adjectives using prepared notecards.”

When documenting the patient’s response to treatment, be sure to:

• Use consistent measurements (e.g. always use percent correct to measure progress towards their dysphagia goal)
• Include objective data “Swallowed cup sips of thin liquid sans overt s/sx of aspiration in 70% of trials”
• Include patient and caregiver reports of progress toward goals
• Be clear why the patient needs continued speech therapy. Basically, show how your patient still needs skilled therapy and is getting better because of your skilled therapy (if that’s the case).

5. Prognosis

The prognosis is your professional opinion of how likely your patient is to benefit from speech therapy treatment. You’ll include a prognosis in documentation that recommends treatment.

These include the Initial Evaluation and Progress Reports. If the patient’s prognosis has changed during the progress report period, include the new prognosis and your reasons for the change.

You don’t typically include prognosis in a Treatment Note (although it will be implied by how they’re progressing towards their goals) or Discharge Report (since you are ending treatment), although some facilities do.

Examples

Excellent 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

Poor Prognosis
Progress may be limited by poor insights into deficits, ongoing medical issues, the severity of deficits, and minimal support at home.

Read How To Generate A Prognosis

6. Plan of Care: Patient Goals

Set your patient’s short-term and long-term goals. You’ll include these in your initial evaluations and progress reports.

INITIAL EVALUATIONS

Write long-term and short-term goals based on the assessment results.

Your goals will bridge the gap between the previous and current levels of functioning. You may need to include a time frame of when each goal will be reached.

Write long-term goals to be achieved by discharge from therapy. While short-term goals are stepping-stone goals to be achieved by the next progress report.

PROGRESS REPORTS

Update your patient’s long-term and short-term goals, if appropriate.

Be sure that your progress report includes the reasons for any updates or changes to the goals.

Example
Under Current Level of Functioning, you write that the patient met their long-term swallowing goal. This explains why you’ve updated to a more advanced swallowing goal.

See our in-depth Goal-Writing Guide and Speech Therapy Goal Bank for more details

7. Plan of Care: Therapeutic Intervention

These are the therapeutic tasks and activities that you recommend for the patient.

INITIAL EVALUATIONS

Document what specific therapeutic interventions the treating therapist will do to help the patient reach their goals.

Be clear why a skilled speech therapy professional is needed for these interventions. If the goal can be reached with only a home exercise program, for example, payers may deny coverage.

In this section, also include your recommendation for the duration and frequency of therapy visits (e.g. 50-minute sessions once per week)

TREATMENT NOTES

Write a short description of the next session’s plan. Name the tasks and activities you plan to use in the next session.

“Continue plan of care” won’t cut it! It’s not specific enough.

Include why the patient still needs your skilled intervention. And if you change the plan of care, describe what will change and why.

Examples:
Continue practicing easy onsets with /h/ initial words. Trial /h/ initial multisyllabic words.

Continue page-level attention task with introduced background noise.

PROGRESS REPORTS

Include the specific therapeutic tasks and activities you recommend for the next progress report period.

Give your reasons for any changes and your recommendations for the duration and frequency of treatment.

8. Coordination With Care Team

Document any relevant communication that 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.)

9. Your Signature & Credentials

If signing by hand, be sure that your credentials are legible! Include all relevant professional credentials. This is your “CCC-SLP” and any other advanced degrees and specialty certifications that you hold.

If you’re a student, this needs to be made clear in this section and to be co-signed (per your payer and state licensure board guidelines).

More Resources

See what speech-language pathologists are saying about The Adult Speech Therapy Starter Pack!

References

• _{American Speech-Language-Hearing Association. (2021). Documentation in Health Care. Retrieved January 26, 2023, 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}