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Documentation here is all computerized. Or well, I should say mostly computerized. Perhaps I should just say, all the paperwork I do is on the computer.
On this system, all the SLPs can make templates for the type of evaluations/treatments they do. By and large, they all follow the SOAP note outline (Subjective, Objective, Analysis, Plan). CI has any number of templates for the evals he might do, bedside swallow, MBS, voice eval, etc. It makes it fairly straightforward to write a note off of these templates. There are even certain commonly used phrases included in the template, e.g. “Pt. denied pain with treatment.” Pain management is an important part of patient care at this hospital for, I think, obvious reasons. I hope other hospitals I work at as actively pursue patient comfort.
The ‘S’ section generally includes any information about the patient’s emotional well-being and/or level of alertness (e.g. “The patient appeared tired as evidenced by repeated yawning.” “The patient appeared depressed as evidence by her flat affect and reduced interest in the session’s activities, a change from usual enthusiasm and up-beat attitude documented in other notes.”) or in regards to any information the patient provides (e.g. “The patient reported changing X medication to Y medication.” “The patient reported coughing and choking after drinking water, soda, and juice.”)
The ‘O’ section is all the objective data. How many questions on the BDAE personal orientation section they answered correctly, the level of laryngeal elevation based on neck palpation, or observing coughing, choking, and a gurgly voice after drinking thin liquids. The ‘O’ part usually goes in order of what happened in the session…probably because that’s just the easiest way for me to recall it. For the swallow SOAPs (both the bedside and MBS), though, it’s a pretty logical progression. CI is very specific about what he wants in the swallow SOAPs, but that doesn’t make it difficult, see my aforementioned statement on “logical progression.” I have outlined it below, for the curious.
Oral Mechanism Function
- Vocal quality
- Labial loss
- Mastication efficiency
- Oral transit efficiency
- bolus formation
- oral stasis
Pharyngeal Phase (Bedside)
- timeliness of initiation
- Laryngeal elevation
- change in vocal quality
- change in O2 sats
Pharyngeal phase (MBS)
- Swallow initiation
- laryngeal elevation
- epiglottic inversion
- Base of tongue/Posterior pharyngeal wall contact
- cough reflex if aspiration
- pharyngeal pocketing
The ‘A’ section is a summary and interpretation of the data provided above. (The emphasis on the ‘and’ there was really more for myself. It just occurred to me that I have really been summarizing more than interpreting my objective data in the ‘A’ section. No one is ever going to read your whole SOAP outside of grad school, most likely only the ‘P’ section; maybe the ‘A’ and the ‘P.’ I guess they might want to know what the data summary means if they’re going to take the time to read the ‘A’!) If the patient coughed and choked after drinking thin liquids, this is indicative of aspiration of thin liquids. A low score on digit span from the Weschler Memory Scale indicates poor short-term memory and therefore directions should be repeated frequently to the patient and probably observed directly to make sure the patient follows them. And so on….
The ‘P’ section is the plan. For me, it is usually the standard “Speech to follow 2-4x /week” and perhaps some indication of why we will be following up. For example, it might be to make sure the recommended diet is still working without apparent signs of aspiration, or to work on orienting the client to person, place, and time. The goals are also listed here.
In any case, I’m learning CI’s method of writing notes which is as short and to the point as possible. I can’t speak for all, but in my experience this is largely in contradiction to how we are taught to write SOAP notes in grad school. In grad school, it’s all about showing what you know. I thought, by and large, my professional writing vocabulary was pretty good, but my level of short-and-to-the-point-ness was incredibly off. (We actually discussed this with our program on our final day, and they agreed to more actively advertise the option of writing much shorter, more “real life”-like SOAP notes after the first semester or so.) I enjoy the notes here much, much more. I don’t have to write in complete sentences, I get to use hospital acronyms (of which I know .001%), I use a lot of bullet points…it’s fabulous! I mean, considering it’s documentation. It is not, I admit, the most fun part of my day.
Pretty thorough, I think. I feel like I was beginning to master CI’s notes (well, except for the elusive ‘A’ section. *shakes fist at ‘A’ section* It’s beginning to come along, though), and now I’m with T for week and the style differences between the two are whiplash different. Just like grad school: you learn to how to write SOAP notes for one supervisor only to discover another’s peculiarities are completely different. Ouch.
Well, the slew of progress reports I have written is more or less done. R and I will go over them this Friday and they’ll be sent out.
I imagine it is up to the discretion of individual SLPs in schools how the progress reports are formatted, although different school districts may have a standard form/format they use. In our progress reports, which are sent out quarterly with the report cards, a child is given a “grade.” ‘A’ is for Goal Achieved; ‘P’ is for progress made with minimal support; ‘E’ for skill emerging with maximum support; ‘N’ area not addressed this period; and ‘C’ consultation see comment. All my kids are ‘P’ and ‘E.’
At the top of the progress reports there is a table with the possible areas of treatment (language, articulation, fluency, voice) along the vertical axis, and grading periods one through four along the horizontal axis. The appropriate “grade” can be put in the correct table cell from there. Below that, I write some brief notes to the parents about what we worked on and how their child has progressed/performed this quarter. Below that is a key for the grades. Pretty simple. It is time-consuming, though, to write short notes about 80 different kids. I’ve spent several evenings attacking these and finally finished my last one (my longest, most detailed one) this evening.
To expand somewhat on the kind of notes I write. R suggested I largely keep percentages out of it. While I am not used to writing SOAP notes like that, but I trust her judgment. Every SLP will know, with time, what the parents would actually want/understand on their child’s speech and language progress report (for the ones who read them at all). I think on my own, and given more time to develop a data taking system, I would likely provide more objective data, but it is important to consider the audience when writing reports of any kind and it would just be common sense to explain what any percentages/numbers actually meant. For you graduate students, just know the sometimes-tortuous process of SOAP notes is not forever.
Next up, leading a case conference for a kid I also evaluated. Hopefully it will go better than the first one I did. (Imagine: fast talking word vomit department of redundancy department.)