How to rock your data collection and documentation with this tool!

We had a problem as a speech team at one of my jobs. We were sharing patients and collecting data differently and documenting our SOAP notes according to our own writing style based on our own system of data collection.

As a team, we wanted to improve our intra-rater reliability. In other words, across multiple clinicians, we wanted to stream line how we were:

  1. Describing out clients subjectively
  2. Listing redirection for attention and behaviors
  3. Describing the therapeutic task/activity
  4. Describing the therapeutic prompting
  5. Measuring the level of prompting (e.g., independent, minimal, moderate, maximal)
  6. Writing clinical reports

So, I created Speech Therapy Data Sheets. I designed it with the busy speech-language pathologist in mind. You will notice the format is specific for the academic setting in the header and footer. However, the actual data sheet content can be used in any setting. I specifically designed this data sheet to:

  1. In the format of a SOAP note
  2. Have check boxes to assist with easy of data collection
  3. Be thorough and comprehensive
  4. List “short hand” goals
  5. Collect data with hierarchy of prompting
  6. Document homework given
  7. Document additional reminders/notes
  8. Use as a tool for teaching/mentoring clinicians
  9. Increase clinical judgement, data collection reliability, and naming/labeling what is actually going on clinically in a session
  10. Improving report writing

A few bonus items! I kept the school therapist in mind when designing this tool.

  1. On the header, I listed information related to ARD/IEP documentation, pull out/push in, time out and in for clinical and billing purposes.
  2. You will notice that I made a short hand version for group sessions.
  3. I also made an editable version for you savvy technology advanced therapists who want to type your quick hand goals instead of writing them.
  4. Plus, you can print multiple copies of pages with written or typed goals in preparation for the entire school year! How’s that for organized?!

I want to give you an example of how my Speech Therapy Data Sheets improve clinical report writing.

Instead of writing a sample paragraph of, “Johnny was hyper and needed reminders to pay attention. He completed a following directions craft. He needed verbal reminders to stay on task, visual/verbal/tactile models/cues, visual supports, the clinician telling him if his answers were correct or not, and checking for understanding after items were discussed to achieve 50% accuracy” a clinical report with my checklist would look more like this: “Johnny was alert, cooperative, and participated throughout. To facilitate appropriate attention and behaviors, he required positioning strategies, visual schedule, frequent sensory breaks, verbal reminders, and positive reinforcers. Target items were elicited during structured language tasks to target following directions. Johnny required visual supports, visual/verbal/tactile models/cues, clinician feedback, and delayed recall to achieve 50% accuracy.”

So you tell me, if you are insurance, which report which report are you going to authorize payment for? Which report writer demonstrated specialized skills? If you are a parent, which clinician do you want treating your child?

If you are a clinical supervisor, which report reflected the actual prompting and skill level you observed in your SLP-Intern, SLP-Assistant, or SLP-Graduate student? Which would you feel most comfortable signing off on?

If  you are clinician, are you needing help being organized, stream-lined with your data collection, and wanting to improve your report writing?

This tool is only $5. Yes! Inexpensive and practical. Isn’t your caseload worth it?

 

 

50% off of Continuing Education July 2017!

One of my favorite vendors, Talk Tools, is having a sale on their continuing education courses! 50% off!!!!!! Talk Tools is a company that specializes in oral motor and feeding difficulties that are impacting speech and eating. I took took two of their videos on demand courses: A three-part treatment plan for oral placement therapy and Feeding therapy: a sensory motor approach. These courses changed my approach to therapy and drastically improved my patients progress toward discharge.

Both of these courses were recommended to me by a speech-language pathologist who has her specialization in feeding on her licensure. I listened to these courses when doing laundry at home. Maybe you too have time to listen in while washing dishes, doing laundry, or tiding up your home? I will say, be prepared to grab a cup of coffee or tea when you get to the demonstrations and recommendations. I even watched certain parts of the videos repeatedly.

On a personal note, I was so thankful I had access to the oral motor course when my son Devyn was born. I completed several of the exercises after his tongue tie was repaired. More on tongue ties later!

I will say, I enjoyed the courses so much and appreciated the systematic approaches toward interventions, that I bought three books. I highly recommend: Oral Placement Therapy for Speech Clarity and Feeding with the Homework Book and A Sensory Motor Approach to Feeding.

Speech-language pathologists, you may have heard or even have been taught at the graduate level that there is not much research on oral motor therapy, it is not evidenced based, and/or it’s not important to work on in therapy. Hold up! Do physical therapists or occupational therapists work on muscle strengthening, range of motion, and muscle grading? It that work evidenced based? Do we have jaw muscles, lip muscles, and is the tongue a muscle? Why wouldn’t there be much research on whether improving oral motor muscle strength, range of motion, and muscle grading affecting speech and feeding? Oh wait, there is research!

Leave comments below on your observations of using oral motor therapy and or using sensory motor approaches in therapy. If you are a parent, what differences do you see? If your therapists, isn’t using these techniques, what are you looking for? What are your concerns? Would love to hear your feedback!

Contact me at stacie.speech@gmail.com, follow me on Facebook at Speech with Miss Stacie, or find me at www.teacherspayteachers.com in my store!

Welcome to my page!

My name is Stacie Neffendorf and I am a pediatric speech language pathologist. I am thrilled to open my first blog! My intention is to encourage other speech-language pathologists in thinking outside the box, assisting with ideas on how to better manage your caseloads, communicate and collaborate with other professionals and parents, and to provide quality information regarding best practices for assessment and treatment! I also encourage parents of children with speech/language and feeding swallowing to follow along! Please invite your students’ or patient’s families’ to join the adventure!

If I could describe my clinical approach in one word, it would be characterized as “thorough.” I just HAAATE missing important details.  I enjoy digging deep to find the best answers for my patients and students. I feel it is my job to capture an accurate picture of theirs strengths and weaknesses, create an evidenced based therapy plan, and to scaffold skills in order to maximize their independence.

I LOOOOOOVE asking the hard questions and figuring out difficult cases. Please e-mail me your question(s) at stacie.speech@gmail.com. If I feature your question on my blog, I will provide you will a free product from my teachers pay teachers store, or will create a custom product for you! Thanks for stopping by!

Contact me at stacie.speech@gmail.com, follow me on Facebook at Speech with Miss Stacie, or find me at www.teacherspayteachers.com in my store!

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