How To Write A Speech Therapy Visit Note
Whether you’re a new or seasoned speech-language pathologist, you’d know that writing speech therapy visit notes is an inescapable part of the job. Although this may not be your favorite part of every visit, it is essential for showing your skilled service and processing billing and reimbursement claims.
Why are visit notes needed?
Tracking Progress
The first and foremost need for a visit note is to track a patient’s progress. It documents a patient's progress over time, helping therapists, patients, and family members monitor improvements and address areas needing further attention.
2. Seamless Communication and Collaboration
Speech therapists often work as part of a larger healthcare team, which can include physicians, educators, parents, and other specialists. Detailed visit notes facilitate effective communication and collaboration among these stakeholders. The notes allow different professionals to stay informed about the client's therapy goals, strategies, and progress, enabling them to provide coordinated care.
3. Insurance and Reimbursement
Speech therapy services are often covered by health insurance plans. Proper documentation through visit notes supports the process of obtaining reimbursement for these services. Insurance companies may require evidence of the medical necessity and effectiveness of the therapy, which can be demonstrated through well-documented visit notes.
What do you write in a speech therapy note?
Visit notes are essential documentation that proves a patient's need for skilled therapy and describes the care provided. To ensure that anyone who reviews the records, even if they were not present during the appointment, can understand exactly what was and was not done, visit notes should be accurate, code-able, understandable, timely, and error-free.
Every agency or company may have a varied style or format for writing their visit notes, but payers like Medicare only need to see certain elements included in a note for it to be considered acceptable.
Below you’ll find the elements of a speech therapy SOAP (Subjective, Objective, Assessment, and Plan) visit note:
Subjective: This section includes the patient's self-reported symptoms and concerns. It may also include information from the patient's caregiver or family member.
Objective: This section includes the therapist's observations of the patient's speech and language skills and swallowing. It may also include standardized test scores or other objective data.
Assessment: This section is the therapist's interpretation of the patient's data. It includes the therapist's diagnosis of the patient's speech and language disorder, as well as their prognosis for improvement.
Plan: This section includes the therapist's recommendations for the patient's treatment plan. It may include specific goals for the patient to work on, as well as the types of interventions that will be used.
Related article: Key Components of a Billable Home Health Note
How to improve your speech therapy visit notes
Use the SOAP note format
Aside from helping you stay focused and organized with your notes, the SOAP helps you save time by allowing you to fill in the necessary information quickly. Using a consistent structure will make your documentation easier to reference, organize, and compare. It will also help you to be more thorough in your documentation and to fill in any gaps in your notes more easily.
Document immediately after the session
Write down your notes right after the therapy session, while everything is still fresh in your mind. This helps you remember the details accurately and ensures you don't forget anything important. The last thing you’d want is to submit an incomplete and inaccurate note.
Keep It Simple
Using plain language in your speech therapy notes is crucial. Avoid using technical jargon or complex terms that might confuse readers. Instead, opt for words that are commonly understood to ensure that everyone, including parents, caregivers, and other professionals, can comprehend the notes. This clarity prevents misinterpretations and ensures that everyone is on the same page.
Be Specific
Including specific details about the session in your notes is essential. Describe the activities that took place, the techniques used, and the goals targeted during the session. This level of detail helps others understand the practical aspects of the therapy and the progress being made.
Example: Instead of writing "worked on speech exercises," you could specify "practiced tongue twisters and vowel sounds to enhance articulation."
Highlight Progress
Focus on the improvements the patient is making. If they've learned new sounds or words, or if their communication is getting better, make sure to note these positive changes.
Take Note of the Challenges
Don't forget to mention the difficulties the patient is facing as well. If there are certain sounds or situations they struggle with, write them down. This helps you tailor future sessions to address these challenges.
Set Goals
Clearly outlining goals for the next session based on the progress made is a critical step. Setting goals helps provide a clear direction for future sessions and ensures that everyone involved is aligned on what needs to be achieved. These goals can be short-term (what you plan to achieve in the next few sessions) or long-term (where you want the patient to be after several sessions). Having goals helps track progress effectively.
Double-Check
Before finalizing your notes, go back and review them. Make sure everything is accurate and well organized. This step helps you avoid any mistakes or missing information.
However, managing several clients can sometimes make reviewing your notes a challenge. To overcome this challenge, you can consider seeking assistance from a home health documentation Quality Assurance (QA) provider. They specialize in conducting thorough reviews of visit notes. This way, you can ensure that your documentation is accurate and complete, making your workload more manageable while delivering quality care to your clients.
Related article: Benefits of Outsourcing Visit Notes Quality Assurance in Home Health Agencies