![]() ![]() Writing treatment notes can help you to become a better practitioner. 3) To stay focused on the plan of care, review how each session went, and plan for future session In other words, the interventions that you document should match the codes that you bill for that session. If you bill CPT codes, your note should also justify the CPT codes you billed and the number of units you billed. Instead, you write “Therapist provided phrase-level expressive language treatment by having patient pair nouns with appropriate adjectives using prepared notecards.” Much better!ġ) works on the patient’s goal (which an earlier assessment proved was an area of weakness-or “need”-for this patient).Ģ) shows that you have the specialized skills that the patient needs in order to improve. This means that you must clearly spell out the skilled services that you provided and why your patient needed them.įor example, let’s say that your treatment note states “Treatment included conversation practice.” A funding source may conclude that they don’t need to pay you for conversation practice-this is something that a layperson could do with the patient. ![]() ![]() Your treatment note should prove to the funding source that your patient needed skilled speech therapy. Liquid notes vst download professional#To justify that the unique skills of a speech-language therapy professional were required during the session This brings us to the second purpose of Session Notes: 2. Most funding sources rely on your notes and assessments to decide if skilled speech therapy is worth paying for. Which interventions worked over the days, weeks, or months? How did the patient respond? Did they meet their goals? The assessment results justified ongoing speech therapy, and you came in to fulfill the plan of care. Either way, they were referred for a speech therapy assessment. Maybe it was an exacerbation of Parkinson’s disease. Your patient first came into your orbit with a presenting illness. Your documentation tells the story of a patient’s episode of care. What’s the Purpose of a Speech Therapy Note?ġ. ![]()
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