Top 4 Patient Documentation Tips for Speech-Language Pathologists

Here’s a scenario most rehab therapists can relate to: you’ve just wrapped up a long day of back-to-back appointments. You open your notebook to decipher your handwritten notes and finalize your documentation only to realize you created something that resembles ancient hieroglyphs. 

Although patient documentation is a commonality across the rehab therapy industry, the goals for speech-language pathologists (SLPs) vary significantly. For example, where physical therapists tend to document more quantitatively (i.e. number of reps), SLP documentation is generally more verbose and descriptive (i.e. patient stated mostly one- to two-word utterances). Still, regardless of the specialty, accurate documentation remains a critical component of patient care—and one that most in rehab therapy are continually trying to bring greater efficiency to. 

To address this issue, we spoke to rockstar SLP Christina Britton, MS, CCC-SLP, the owner and founder of Eat, Talk & Play Therapy, which specializes in pediatric speech-language and feeding therapy, to get her best tips and tricks for creating complete and accurate patient documentation. She shared a few ways she’s leveraged technology to bring efficiency to the process—and perhaps even begin to enjoy the process. 

1. Utilize an electronic documentation system.

Today, the vast majority of rehab therapists (more than 85%, to be exact) are using an electronic documentation system. It’s proven to be a game changer for therapists not only in terms of efficiency, but also in being able to locate and share patient information with other providers. 

“When I started my own business, one of the first things I did was get an electronic charting system,” Britton said. “When you have documentation on paper, things get lost, are illegible, and can leave room for more errors.” 

Look for a system that matches the SLP workflow. It should be intuitive and include things like assessment fields specific to SLP, or fields with dropdowns or boxes that can quickly be selected to complete reports. 

Britton’s tip: Demo different electronic charting systems to see what works for you and your goals. Make sure it provides a good experience and is logical for you. “For me, I like the ability within WebPT’s SOAP notes to quickly customize my reports as I’m working versus having to create a whole new template,” Britton explained. “I can add sections I think would be beneficial to that specific patient. I also don’t have to write long narratives anymore because there are menus I can quickly choose from to just click through the report.” 

See WebPT’s next-generation documentation solution in action—and start saving time on SOAP notes today. 

2. Document as you go.

It can be tempting to leave documentation until the end of the day, but this can lead to incomplete or inaccurate notes. And let’s be real: after seeing eight to 10 patients in a day, you are bound to be exhausted. In some cases, the “end of the day” can also turn into weeks or months depending on your clinic’s reporting schedule. Attempting to sift back and decipher past notes you quickly scribbled in your notebook to recall a patient’s visit can set you up for failure in the long run.

Britton’s tip: Consider writing your report while you’re working with the patient. Of course, this will depend on your clinic’s processes and technology, but being able to do this quickly on a device such as an iPad will save a ton of time—and ensure greater accuracy in the long run. 

3. Document with other therapists in mind.

Good documentation is a vital component of your practice as it provides a cohesive roadmap for you or another practitioner to follow throughout the care journey. Ultimately, you should be able to generate a descriptive report that can be easily deciphered and implemented by you or another therapist. 

“At any point, another therapist from any field should be able to read my report or note and be able to know exactly what I was doing, and be able to implement that,” Britton said. “That’s the whole purpose of good documentation. They should be able to know exactly what you did based on your documentation—having never met you or the patient.”

This also dovetails into the importance of documenting defensibly. In the event you are ever audited by a payer, your documentation must be able to prove that your treatment plan was medically necessary. To this end, proper documentation does more than just improve communication between providers, but it also demonstrates your compliance and justifies your charges.

Britton’s tip: While you are drafting your report, think about how you might interpret the notes if you were receiving them from another therapist or having to revisit the patient after a long gap between the initial evaluation and the first treatment. Ask, “If someone else in my field were to pick up this report, would they be able to implement this plan?” 

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4. Create a template.

Creating a template with customized fields you know you will routinely use will help speed up the documentation process. And for busy SLPs who might have up to 40 patients a week, it will prove a game changer. 

“Every therapist has their own style. Every clinic has its own style,” Britton said. “Having those templates and automated fields already established makes it a lot easier. Therapists don’t get many breaks and when you do get one, you have to be efficient –– and that’s the purpose of the template.”

Britton’s tip: Spend some time on the front end creating a template and list of general goals you tend to use the most so you can quickly click through the documentation process. If you are a manager and you're the one making the template, you can give your therapist these goals to choose from to make their documentation more seamless. 

Patient documentation doesn’t have to be a painstaking process. By finding techniques that work for you—and pairing them with the right technology—you can maximize your efficiency, organization, and save yourself a headache down the road. If you have any other SLP documentation efficiency tips you think we should know about, please drop them in the comment section below!