Clinical Documentation

types of documentation

educational

• full individual evaluation

• individualized education plan

• daily note

• progress report/IEP update 

• admission review dismissal

medical

• assessment/evaluation

• plan of care/treatment plan

• session note

• progress note

• staffing

Form

phonology - sound system

morphology - word structure

syntax - sentence structure

content

semantics - vocab

use

pragmatics - language in context

domains of language

form, content, use

SMART goals 

(s)pecific - what will the client do

(m)easurable - how much? how often? how accurately? 

(a)ttainable - is it within their zone of proximal development

(r)elevant- will it make a difference in their daily life

(t)ime - how long will you work on it 

SOAP notes

(s)ubjective

(o)bjective

(a)ssessment

(p)lan

ASHA Big 9

• artic

• fluency

• voice & resonance

• language

• hearing

• swallowing

• cognitive aspects of communication

• social aspects of communication

• AAC

Components o f a Treatment Plan

1. Identify goal areas – ASHA Big 9

2. Long Term Goals

3. Short Term Objectives

4. Strategies/Therapy Approaches to target each goal

5. Service Delivery (frequency/duration)

Goal Writing

must be client-centered and measurable!

Creating goals

client + behavior + criterion + condition