Progress and Discharge Reports Notes

Therapeutic Methods: Progress and Discharge Reports

The Therapeutic Process

Pre-Treatment Tasks
- Gather Data
- Choose Treatment Targets
- Write Goals
- Determine Baseline
- Session Planning and Implementation
  - Determine Teaching Methods
  - Develop Scaffolding Strategies
  - Develop Generalization Plan
  - Create Treatment Activities
- Session Documentation
  - Data Collection
  - Document SOAP Note
  - Write Progress Note/Report

Progress Report vs. Discharge Report

Progress Report: A periodic report summarizing treatment within an episode of care.
- Typically at the end of a treatment period (e.g., semester, trimester, school year, billing period)
- Important: This is NOT an assessment report.
Discharge Report: A report documenting that a client will no longer receive services at that particular site.
- Reasons for discharge:
  - No longer requires service (goals met)
  - No longer benefiting from services
  - Poor attendance/stopped coming (policy)
  - Lack of funding
  - Change of address (outside scope of license)

Parts of Progress/Discharge Reports

Identifying Information

Client Name
Date of Birth
Age
Sex
Handedness (L/R)
Date of Report
Student Clinician
Supervisor

Background Information

Be Brief: Concise statement of diagnosis/disorder or relevant history to intervention.
Type of treatment and broad areas of intervention.
Length of treatment (how long the client has been receiving services).
Frequency and duration of services.
The period of time this note covers.
Attendance?

Example 1: Background Information

Hal has been receiving individual speech and language services at Biola University Speech Clinic since September 2017 to address his anomia and fluency following a CVA with Broca’s Aphasia in 2011. This progress report covers the Fall 2024 semester, ranging from September 12, 2024, to December 16, 2024. John attended 10 of 12 total sessions, offered 1 time weekly for 50 minutes each session.

Practice Exercise

Guidelines for analyzing background information:
1. Place a star next to the diagnosis/disorder.
2. Circle the treatment type.
3. Place a single underline beneath areas of intervention.
4. Place a double underline beneath length of treatment.
5. Place a box around frequency and duration.
6. Place a bracket around the period of time in the note.
Example Scenario: Kelly is a 6-year-old autistic girl, referred for expressive language delay. She has been receiving individual language intervention to improve receptive and expressive semantics since Spring 2023 for 50-minute sessions, 1 time weekly. This note presents progress from weekly, 50-minute sessions of intervention provided in the Fall 2024 semester, with dates ranging from August 2024-December 2024.

Summary of Therapy Progress

A. Area of Need
- Initial Status:
  1. Qualitative description of initial status.
  2. Baseline Statement
- Current Semester Goal: LONG TERM GOAL only
- Current Status:
  1. Objective statement on progress toward goal
  2. Analysis of the objective data.
- Repeat for all goals in the episode of care.

Example 1: Summary of Therapy Progress

A. Expressive Language: Mean Length of Utterance (MLU)
- Initial Status: Based on a 50 utterance language sample gathered at the beginning of the semester, Kennedy produced language with an MLU of 1.2. She used 3-word utterances in 8% of opportunities. Other utterances were 1-2 morphemes, containing a noun, article + noun, or single verb.
- Current Semester Goal: By December 10, 2024, Kennedy will produce utterances with an MLU of 3 during play-based activities, as measured by spontaneous language sample analysis.
- Current Status: Kennedy met this goal. She produces utterances with an MLU of 3.2 during play-based activities. Kennedy can combine article, noun, and verb without conjugation to expand verbal expression. ${Baseline Data Statement + Qualitative data}$

Example 2: Summary of Therapy Progress

A. Stuttering: Fluency Shaping
- Initial Status: Following dynamic assessment, Owen was able to use the easy onset fluency shaping strategy in 3% of opportunities in a 5-minute conversational task. He used the strategy one time within the 5-minute sample. He was able to use easy onset with 60% accuracy at the word level and 30% accuracy at the sentence level when responding to a question in conversation.
- Current Semester Goal: By December 15, 2024, Owen will use the easy onset fluency shaping strategy in 80% of opportunities during a 5-minute conversational task in the treatment room, as measured by clinician observation.
- Short-term goal: By October 25, 2024, Owen will use the easy onset fluency shaping strategy in 80% of opportunities when responding to a question in structured conversation in the treatment room, as measured by clinician observation.
- Current Status: Owen did not meet this long-term goal; however, he met his short-term goals for word level and sentence-level use and made progress toward conversational use. Owen can use an easy onset fluency shaping strategy in 50% of opportunities during a 5-minute conversational task in the treatment room. {Document Long Term Goal & (only if necessary) Short Term Goal}

Example 3: Summary of Therapy Progress

A. Articulation: Prevocalic R
- Initial Status: Riley could produce initial /r/ at the word level with 0% accuracy. She was not stimulable for the /r/ in any context; Riley could follow placement cues for accurate posterior elevation without improvement in production.
- Current Semester Goal: By December 16, 2024, Riley will produce initial /r/ at the word level with 80% accuracy given 1 verbal cue, as measured by clinician observation.
- Current Status: Riley has met her semester goal. She can produce initial /r/ at the word level with 50% accuracy independently, increasing to 85% accuracy given one verbal cue to maintain posterior lingual tension. She can maintain accuracy at the sentence level following drill of the target word. /R/ production sounds effortful in order to achieve proper tension. Carryover is not observed in spontaneous speech at this time. Parents have been instructed on specific prompts for eliciting initial R during home practice activities.
- Include: Quantitative Data, Qualitative Data, and Analysis (O & A) from the most recent SOAP Note.

General Impressions

Any other miscellaneous information that is relevant to intervention.
Observations of behavior.
Observations of other health or developmental concerns.
Parent Reports.
Summary of treatment: goals met or progress observed; efficacy of treatment; continued concerns.

Example 2: Summary of Therapy Progress

Impressions/Summary: Dakota has demonstrated high motivation throughout all therapy sessions. Hands-on therapy material is motivating for Dakota. Initially, Dakota would speak softly when eliciting the speech sound target during therapy. Currently, Dakota speaks louder and has increased her participation in therapy sessions. Dakota has made significant progress toward all goals, including prevocalic and vocalic /r/, improving from 0% accuracy to 60% accuracy given verbal prompts for tongue placement and tension. Oftentimes, Dakota’s elicitations were more accurate when scaffolded down to the phonemic level before elicitation at the word level. Dakota has been observed to be more accurate when elicitations were at a slower rate and requires cues to increase the rate of elicitation.

Example 1: Summary of Therapy Progress

Impressions/Summary: Finn is a very hardworking, motivated individual. During sessions, Finn appeared to be very attentive, listened and engaged appropriately, and worked very well. Finn displayed appropriate behavior during sessions. Finn’s special interests include board games and coloring. During intervention sessions, Finn improved the accuracy of targets when provided verbal and visual cueing for lingual placement, airflow, and monitoring his breath and rate of speech. He was often self-reflective, noting instances in which his production of /s/ sounded lateralized. Finn demonstrated growth when participating in both drill-based and naturalistic intervention methods.

Recommendations

Service recommendation statement.
Any other relevant recommendations:
- New areas of concern
- Needs for further assessment
- Referrals to other professionals

Example 1: Recommendations

It is recommended that Dakota continue speech therapy once a week for 45-minute sessions.

Example 2: Recommendations

It is recommended that Loren continue receiving speech services at Biola Speech and Hearing Clinic for one 45-minute session during the Spring 2025 semester. A standardized language assessment should be conducted due to parent concern sentence expression. It is also recommended that a formal hearing evaluation be conducted by a licensed audiologist to rule out hearing loss.

Goal Areas and Treatment Plan

GOAL AREAS FOR NEXT SEMESTER
- Expressive language, using 2-3 word sentences with no prompts. (Indicate basic goal areas, not specific goals. Next semesters clinician will conduct assessment to determine specific goal levels.)
TREATMENT PLAN

Example 1: Goal and Treatment

GOAL AREAS FOR NEXT SEMESTER: Dakota’s goals for the next semester will continue to target articulation for the prevocalic and vocalic /r/ at the word level.
TREATMENT PLAN: Dakota will benefit from oral placement practice with continual drill at the word level. Upon mastery at the word level, it is recommended that Dakota progress to the phrase, sentence, and conversation level. Prompting should be faded to promote independence.

Example 2: Goal and Treatment

GOAL AREAS FOR NEXT SEMESTER
- Articulation: Finn will produce /s/ in all positions of words at the sentence level with moderate cueing.
- Fluency: Finn will use fluency strategies and monitor his breath support while reading and speaking.
TREATMENT PLAN: When working with Finn, a hybrid intervention approach is recommended. For speech therapy, a traditional articulation approach is recommended to address Finn’s production of /s/. Finn demonstrates increased accuracy with drill and verbal cues to support placement. For fluency, it is recommended that a naturalistic, conversation-based approach is taken to improve self-monitorings and promote generalization of Finn’s use of fluency and respiratory strategies.

EDIT and SIGN

When you sign a report, you are “stamping” your license to the report.
Editing is the most important process of writing a report. DO NOT SKIP EDITING.

Lab 5: Progress Report

Individual Lab: Download a Progress Note Template. Using your "class client" and the goals, baseline statements, and SOAP notes you've written for that client, write a Progress Note. If you do not have information, create some.