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?

 

 

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