Speech Therapy
Documentation Examples
Translating assessment documentation based on audience
CONTRIBUTIONS
Clinical documentation for insurance companies and patient/family
ROLE
Technical Writer
PROBLEM
Clear documentation is an essential skill for a speech therapist. I had to write for different audiences: the patient’s family, my interdisciplinary team, and the insurance companies.
If my documentation lacked key, relevant information, services could be denied by the insurance companies. On the other hand, if my writing was full of medical jargon, the family members would be left confused and concerned. My ability to write for different audiences played an integral role as a speech therapist.
SOLUTION
Below is an example of how I rewrote an assessment paragraph based on the audience and the goal (all details are fictional). When writing, I kept in mind the purpose of the document and the audience. I was careful to explain any unfamiliar terminology when writing for the patient’s family.
AUDIENCE: Insurance companies
GOAL: Prove the patient’s need for speech therapy services
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Mr. Doe presents with moderate-severe expressive language deficits and moderate receptive language deficits, most consistent with Broca’s aphasia following a left cerebrovascular accident (CVA). Verbal expression is characterized as nonfluent, with frequent anomic episodes, a mean length of utterance of 2-3 words, and groping of articulators. Automatic speech is preserved; however, the patient demonstrates significant difficulty to communicate basic wants and needs volitionally. He is unable to call his family members’ names or state what he would like to eat for breakfast due to his aphasia. Suspected concomitant apraxia of speech; further assessment to be administered next session. Auditory comprehension is a strength. He is able to answer reliably to personal, basic, contextual yes/no questions via head shakes and nods. He requires more support for complex, non-contextual questions, benefiting from written keywords, pictures, and reduced length of sentences. Reading comprehension is intact for his name and 3-letter word. Written expression is characterized by the emerging ability to write the alphabet and numbers 1-10; he is also able to copy letters reliably. Due to his communication deficits, Mr. Doe is unable to participate in the community, converse with his family and friends, and unable to complete his vocational tasks as an elementary teacher. The burden of communication falls heavily on his wife to help him communicate and decipher his communication efforts. Skilled speech therapy services are warranted for the treatment of speech/language deficits, patient and family education, and home program instruction.
AUDIENCE: Patient’s family
GOAL: Inform the family of the patient’s results from the initial evaluation and goals for speech therapy
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Based on his initial evaluation, John Doe presents with a type of nonfluent aphasia called Broca’s aphasia. Aphasia is a communication disorder that often follows a left stroke. Aphasia can impact the four domains of language: verbal expression, auditory comprehension, reading comprehension, and written expression. Each domain can be affected with different severity. John demonstrated strengths in auditory comprehension and reading comprehension, with more weaknesses in verbal expression and written expression. He has significant word-finding difficulty in conversation; this does not mean he has a memory impairment, but rather a communication impairment. John knows what the word is, but he has trouble accessing that word when he wants to say it. In speech therapy, we will work together to rehabilitate those four domains of language, establish and implement a home program for continued practice, and discuss how to best help John communicate.
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