Documentation may be an inescapable part of the job, but we are here to make it as efficient and painless as possible!
In this article, we’ll cover how to write a progress report for your adult speech therapy patients.
You’ll learn exactly what you need to include, per major funding sources’ requirements (health insurance companies and U.S. Medicare Part B). Plus, you’ll find a speech therapy progress report example!
While this article outlines the fundamentals of a progress report, your employer and funding sources may have their own guidelines for documentation. Be sure to follow them!
For documentation and assessment templates, visit our shop!
More Documentation Help!
- Why Write Progress Reports, Anyway?
- What Should A Report Look Like?
- 10 Elements Of A Speech Therapy Progress Report
- Speech Therapy Progress Report Example
- More Resources
Why Write Progress Reports, Anyway?
The purpose of a progress report is to justify the medical necessity of your treatment.
You write your report to:
- Show patient progress. Your report will explain how the speech therapy you provided during the progress report period helped the patient improve
- Continue treating the patient. It will also show how continued speech therapy will help the patient reach their maximum potential
What Should A Report Look Like?
Every employer’s progress 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 10 elements to include in your progress report, followed by a speech therapy progress report example.
10 Elements Of A Speech Therapy Progress Report
1. Progress Report Period
Include the dates that your progress report will cover. We’ll call this the progress report period.
How often you write a progress report will depend on the funding source and your employer. An example progress report period may be from the date of the initial evaluation to the most recent treatment session.
2. Date Report Was Written
Be sure to include the date that you wrote the report!
Include both the patient’s medical and speech therapy diagnoses.
4. Previous Level of Functioning
In your progress report, the PLOF is your patient’s status at the beginning of the progress report period.
Include relevant objective information to more accurately measure progress.
These are the standardized tests, measurements, and/or data from the previous progress report.
If you’re writing the patient’s first progress report, then use the objective data from the initial evaluation.
5. Current Level of Functioning
Your summary of the patient’s current level of functioning will be based on the subjective and objective information that you gathered during the progress report period.
In this section, include:
- A summary of the patient’s progress toward their goals
- A summary of the patient’s response to treatment
- Whether they met each goal or not. If not, explain why
- Objective tests, measurements, and data
- Patient/caregiver’s reports
- Successful interventions. List the tasks/activities, strategies, cues, etc. that helped the patient improve
If the patient’s prognosis has changed during the progress report period, include the new prognosis and your reasons for the change.
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
Update your patient’s short-term and long-term goals.
Be sure that your report includes the reasons for any updates or changes to the goals.
For 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.
- 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
List the specific tasks and activities that you recommend for the patient during their next progress report period.
- Identify the specific speech therapy interventions. Safe swallowing strategies, LSVT Loud, complex problem-solving tasks related to money management, etc.
- Include your reasons for any changes from the previous progress report period
- Include your recommendations for the duration and frequency of therapy for the next progress report period
9. 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.)
10. Your Signature & Credentials
If signing by hand, make sure that your credentials are legible!
Speech Therapy Progress Report Example
Time Period of Progress Report: From 04/19/22 to 05/12/22
Report Date: 5/12/22
Diagnoses: L frontotemporal infarct, hypertension, hyperlipidemia, asthma, moderate oropharyngeal dysphagia.
Patient’s status at the beginning of the progress report period: At the beginning of the reporting period, Mrs. Jung safely tolerated a minced & moist and slightly thick liquid diet given occasional minimal verbal cues to use safe swallowing strategies.
Patient’s current status: Mrs. Jung demonstrated good progress toward ST goals during this reporting period. SLP provided training in the use of liquid wash, effortful swallow, and bolus hold (3-second prep). SLP also provided extensive training in the use of swallowing strengthening exercises, including Mendelsohn (laryngeal lift) and effortful swallow (oral/pharyngeal squeeze). MASA was repeated, and patient scored 182/200 (within normal limits) given soft & bite-sized textures and thin liquids. Despite the normal score, Mrs. Jung remains at risk for aspiration secondary to R weakness and slightly delayed swallowing initiation (~1 second delay). She continues to demonstrate occasional throat clearing post swallows of diet textures, though vocal quality is clear and dry post trials. She demonstrated no s/sx of aspiration post cup sips of thin liquids in 90% of trials. Mrs. Jung reported completing strengthening exercises twice daily, per recommendations. She also reported that her daughter, Mei, has lunch with her most days and provides occasional verbal cues for use of swallowing strategies.
Prognosis: Prognosis is good given good progress thus far, high motivation, follow-through with home program, and family support. Patient will likely upgrade to thin liquids by the next reporting period.
Plan of care (Therapeutic Interventions): Recommend MBSS to evaluate swallowing safety given soft & bite sized textures and thin liquids. Recommend continued dysphagia treatment with speech therapy to continue in the training of safe swallowing strategies and diet trials to increase the patient’s ability to safely consume the least restrictive diet.
Plan of care (Goals): Long-Term Goal: Safely consume PLOF diet
(regular/thin) using safe swallowing strategies IND in 1 month.
Previous Short-Term Goals: Utilize safe swallowing strategies in 100% of opportunities given minimal verbal cues. Safely consume a soft & bite-sized diet with slightly thick liquids sans overt s/sx of aspiration in 80% of trials given occasional verbal cues to utilize safe swallowing strategies. Goals Met.
New Short-Term Goals: Utilize safe swallowing strategies in 100% of
opportunities given occasional verbal cues. Safely consume a soft & bite-sized diet with thin liquids sans overt s/sx of aspiration in 90% of trials given occasional verbal cues to utilize safe swallowing strategies.
Coordination with care team: This SLP left a voice message with SLP at Local Hospital regarding upcoming follow-up MBSS.
Therapist’s signature & credentials: Ana Garcia, M.S. CCC-SLP
See what speech-language pathologists are saying about The Adult Speech Therapy Starter Pack!
- 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