If it’s not done properly, or not done well, the event never happened and you may not get paid! Most speech therapists are trained in how to write a report. But one size does not fit all. Here are general things to keep in mind when doing documentation.
- Who is the audience? If you are writing for other professionals, then use “speechy language” (“phonological processing”, “laryngeal stage dysphagia”). If you are writing for Medicaid, or Medicare, these terms are useful but should also be explained in the report. If writing for parents, don’t get too technical.
- What is the purpose of the report? Of course you need to report test scores etc. But you often need to prove to insurance why they should pay for speech therapy services. Insurance companies want to save money so sometimes they look for reasons to deny services. Remember to “make your case”! Statements such as: “This child exhibits a severe articulation delay. He is 20% intelligible to new listeners without contexts. The severity of his articulation delay interferes with his ability to get his needs met at home and at school.”, can help you make your case to an insurer.
- Are your notes and evaluations clear enough so that another professional can take over your case and generally understand what to do? You don’t need to go into minute detail for your sessions, but another speech therapist needs to be able to discern what was done and if any progress is being made.
- Remember, documentation can also be used for legal purposes. Write professionally.
Guidelines exist for documentation across various settings. But for complete answers to your specific documentation questions, please visit the ASHA website. As you know, health care and school setting guidelines are always changing. So make sure you keep current and stay informed.
About the Author
Sandra Alexander has over 20 years of experience in the speech therapy field. In 1994, she received her Master’s Degree in Communicative Disorders from San Diego State University and in 1985 she received a B.A. in Communicative Disorders from the University of Redlands. She is also a returned Peace Corps Volunteer who taught speech therapy in Ecuador from 1987-1989.