As a pediatric speech therapist, you know that defensible documentation (i.e., clear and detailed notes) is an essential part of demonstrating your skilled service and getting paid.
Whether you use clinic software or the old pen and paper method, managing your SOAP notes and evaluations can easily become overwhelming when working with multiple patients. But you don’t have to let that affect the quality of your notes.
In this article, I’ll cover some guidelines you can follow to improve your SLP documentation with or without speech therapy documentation software. And remember: better notes mean better therapy and less claim denials.
While every SLP has their own way to document their sessions, these guidelines can help you write notes that include the critical information and present those details in a way that's easy to digest for caregivers and other therapists. I've also included a SOAP note template and some other helpful resources at the bottom of the post.
Feel free to take this information and tailor it to your own note-taking style!
If you need a refresher on the SOAP method of note taking here's a reminder:
Whether you're using our SOAP note template, or you're creating a template of your own, it will help to keep those details in mind.
The elements of a good SOAP note are largely the same regardless of your discipline.
Your SOAP notes should be no more than 1-2 pages long for each session. A given section will probably have 1-2 paragraphs in all (up to 3 when absolutely necessary).
That's enough to give a solid overview of what each session involved, how the patient is progressing, and what you anticipate working on in the near future.
Keep in mind that length requirements, exact formats, and abbreviations vary from one employer to the next. This is where a template can come in handy.
You should never hesitate to check your employee handbook or ask about the best way for you to handle your SOAP notes so that they are consistent with what your supervisors want to see.
Whenever you're writing a SOAP note, be sure to keep its purpose in mind. Oftentimes, speech therapists write so many notes that they occasionally lose sight of the real purpose of these notes.
The purpose is to clearly inform caregivers and other therapists about the patient's current status and progress. They're also used to document the need for these sessions to an insurance company so that you can be reimbursed.
Here are seven documentation guidelines that will help improve the quality of your SOAP Notes as a Speech-Language Pathologist.
Following a template will be beneficial to your management and organization techniques. You can find plenty of templates online and then adapt them to fit your own unique approach. (In fact, there’s a free SLP SOAP note template at the bottom of this post!)
You may not always fill out every section of the template for every patient report. If that's the case, simply leave those sections blank and write in the information that's important where it belongs.
Following a consistent structure will help you with reference, organization, and comparisons later on. It will improve your level of detailed documentation while also making it easier for you to "fill in the blanks" and finish your notes accurately.
A SOAP note template will also make sure that you are consistently tracking the most important information for each patient.
In order to write defensible documentation, you should be creating a unique note for each and every appointment.
The note that you create for each child following every session should describe the patient’s goals and treatment in a way that's relevant to each individual patient. Different activities and interventions should be clearly justified.
Avoid "cookie cutter" notes that are generic, vague, and/or look the same for all the children you work with. These are a red flag for insurance claims reviewers.
If you're using EMR software, you should find an option with a wide selection of content that's able to be customized with unique responses, outcomes, and goals tailored to each child.
When it comes to your SOAP notes, writing goals is crucial. However, setting too many goals can hinder your treatment plan. So be specific to each patient when prioritizing the goals and think about what limitations are the most challenging for them in day-to-day life.
When you create goals, be sure that they are SMART goals. SMART goals are easier for caregivers and other involved parties to digest and support.
A SMART goal is:
SMART goals break down a goal so that you can look at each aspect and set a date for the goal to be reached.
They also allow you to plan what needs to happen along the way for you to get there.
Make sure each patient's long-term goals are as functional as possible. You should set short-term goals that help them reach their long-term goals incrementally, keeping them motivated and on the right path.
The best time to complete your notes is immediately after a session when everything is fresh in your mind. Putting off your notes will increase how long it will take you to be reimbursed for the treatment.
Additionally, the further removed you are from a session, the less you will be able to remember when it comes time to write your notes. This can hinder the treatment plan and lead to you forgetting important details.
If you are not using an electronic system and you have opted for pen and paper, be sure that your notes are neat and legible, not only for yourself but for your patients and their caregivers as well. Your notes should be easy to read and structured in a very clear, streamlined way.
One way to keep your notes easy to read is to print out your template and writing directly into the note when it makes sense (even if you don't use that as your final note).
Documenting each individual session is how you provide evidence about the quality and efficacy of your treatment plan. When you forget or exclude details, caregivers can begin to question the quality of the care you're providing.
The more details you're able to write about a given session, the better. These details will help you stay consistent with your treatment methods and replicate your approach where needed.
They can also help you better communicate with other therapists who may be working with your patients to ensure they can pick up where you left off.
While you should be detailed with your reports and include all the important and pertinent information, don't fill your reports with unnecessary information. This makes it harder to read, longer to write, and more difficult for others to process. It will also clutter your note review process.
Focus on writing better, not necessarily more. Know what information is needed in order to tell the story of functional outcomes and medical necessity for your treatment plan.
That's how you write good notes that will ultimately be reimbursed.
Here are a few extra tips to help you with your documentation. Like the guidelines above, these tips will help reduce claim denials and improve the effectiveness of your therapy.
If you have not already begun to use therapy documentation software to keep track of your SOAP notes, there is no better time to start. Nothing beats the versatility, ease of sharing, and security of good speech therapy practice management software.
There are multiple systems out there that you may use to handle your SOAP notes. Your clinic may even already have one in place. If that’s the case, your priority should be learning how to use the system to the fullest.
Oftentimes, even if you know how the basics (like how to create and submit a new note), you may be missing out on some valuable tools that you haven’t yet learned how to access.
On the other hand, if you are still using pen and paper or just a basic Word template for your notes, it's worth looking into an electronic system that can help you submit your notes more efficiently and be more accurate with your note-taking.
You can find both locally installed software for your work computer and even some cloud-based platforms that can be accessed online whenever you need them.
As times goes by and these systems become more advanced and convenient, it’s likely your clinic will be switching to one in the future anyway. Getting ahead of the curve and learning how to use one of the more popular systems can help you stay relevant in the workforce and may even open up new doors for you at another clinic where such systems are already in place.
Perhaps the absolute best advice you can take as a SLP is getting caregivers actively involved in the speech development of their child. In your SOAP notes, you should be sure to document all home education programs and other activities the child is participating in to help develop their skills.
This is also required by many insurance companies who have requirements for caregiver education and home programs. You should document all education that you are providing to the caregiver including any training you provided about interventions and strategies they can implement at home.
In addition to including pertinent information that will help your patient with their development, you also need to double-check all your notes against a template and your clinical guidelines to ensure that you will be reimbursed by the insurance company for your work.
You should also know what services you should be billing for and make sure you are documenting them accurately. Additionally, know when you should bill for the time spent completing your notes as that can be a time-consuming process as well.
Using action words helps to demonstrate the skilled services that you are providing, which is something insurance companies look for when reviewing claims.
You can find multiple "cheat sheets" online filled with action words tailored for your SLP SOAP notes. These action words can help speed up the note-taking process while also assisting you with documenting the skilled speech therapy services you are providing. accurate, detailed documentation for each session you complete with a patient.
Some key action words include: adapted, addressed, adjusted, clarified, coached, collected, delivered, demonstrated, drilled, established, evaluated, expanded, familiarized, formulated, guided, habituated, identified, initiated, monitored, observed, prompted, reinforced, and so on.
The use of action words can help better illustrate a challenge, progress, or goal that you are attempting to document. Using the right action words can help make your notes clearer and more concise while adding significant value to everything you detail about a given session.
The last tip for perfecting your SOAP note-taking method, is to find some great examples to learn from.
This kit includes:
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