therapy life & documentation

Templates for Speech Therapy Notes

templatesnotes

A few years back I purchased Northern Speech services ‘Medicare Guidelines Explained for the Speech-Language Pathologist’  – a noteworthy resource for me as I transitioned from the school to skilled nursing setting.  It taught me how to write describe my services with emphasis on the skilled training provided.  I learned how simple and quick documentation can be once you have a framework or template as the foundation.

In my current hospital we have since switched from narrative paper-based documentation to electronic, so the need for this type of documentation style is no longer necessary.  However, I’d still highly recommend this book as a resource to SLP’s new to documentation writing for reimbursement and justification of skilled services

Here are a few documentation templates I used based off of examples provided in the book.

Templates for Weekly Narrative Notes:

Training and instruction provided to improve ____.  Patient is making gains towards STG’s.  Patient demonstrates improved ____ (skills here) as a result of skilled intervention.  Education provided on ____.  Difficulty continues for ____. Recommend continued skilled ST to return patient to PLOF and/or max level rehab potential prior to d/c.

OR

Continued training and instruction to improve ____.  Patient is making limited gains towards STG’s due to ____.  With more time and skilled instruction, patient demonstrates potential to ____.  Education provided on ____.  Difficulty continues for ____.  Recommend continued skilled ST to return patient to PLOF and/or max level rehab potential prior to d/c.

Templates for Re-certifications:

Positive response to skilled ST noted.  Training and instruction to improve ____has resulted in improved ability to____.  At the start of care, patient could not_____.  Now the patient can_____.  Patient continues to require skilled rehab for________.  With additional training and instruction, patient has potential to_____.  Recommend continued skilled ST to return patient to PLOF and/or max level rehab potential prior to d/c.

OR

The patient continues to show positive response to training and instruction.  Next step in treatment program will be to provide additional training and instruction to ______.  Patient continues to require skilled rehab for________.  With additional training and instruction, patient has potential to______. Recommend continued skilled ST to return patient to PLOF and/or max level rehab potential prior to d/c.

2 comments on “Templates for Speech Therapy Notes

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