Speech Documentation

Learn how to complete speech documentation for a patient. This article includes information on creating initial evaluations for patients with Medicare and Non-Medicare insurance types and key fields for SLPs.

Remember, your user type should be SLP to automatically load the Speech Profile in your patient notes.

Initial Examination

In the patient records section of the patient chart, use the play button to begin the Initial Examination. Please note that the process below shows which fields are required to finalize the note, however, this does not mean that these required fields are the only fields you should complete for proper documentation.

SOAP Note Tabs

The Subjective tab allows you to enter key information about the patient's Diagnosis, Medical History, Current Complaints, and start reporting on Functional Limitations. 

Basic Info

In this section, the following fields are required and must be completed:

• Date of Initial Examination and Start of Care (these default to today’s date)
  
• Diagnosis and Treatment Diagnosis(these fields will populate with the diagnosis listed in the patient’s case). 
  
• Injury/Onset Date/Change of Status Date (this must be prior to the Date of Initial Examination). 
  

If your user type is set to SLP in the application, the Speech Profile drop-down will automatically be selected. This changes the documentation to suit the needs of a speech therapist.

Medical History

While there are no required fields here, it's important to note that this section contains speech-specific diagnostic questions, including Cognition, Vocal Quality, Oral-Motor issues, etc.                   

There are also additional speech-specific Medical History options highlighted in blue.

The Objective tab is preloaded with speech-specific tests and measurements, indicated by the Speech designation on the right side of the screen.

To access additional tests, let’s review how to add Speech Evaluations to the Outcome Measurement Tools section. Additionally, If you want to customize the tests and measurements available, you can create your own examination profile using the steps outlined here.

1. In the Add Tests search bar type speech.
2. You can select the Speech-specific test you’d like to include and use the Play Button to add. 
   
3. If you want to include additional custom tests and measurements you can use the Additional Comments box in the appropriate section.        
   

Medicare Only

In this section, you must complete one OMT if you are treating a Medicare patient. If you don’t find an OMT that works for you, you can use the Custom Outcome Measurement selection. Remember to upload the completed test into eDoc.

For the Assessment tab:

Medicare Only

• You must include a Severity % Rational based on your OMT
  

The Plan section allows you to select the patient’s treatment plan from speech-specific and general rehab therapy checkboxes. The only required field in this section is Frequency for Medicare Patients.

Medicare Only

When treating Medicare patients, it is recommended that you create a Plan of Care document by selecting the checkbox. Regardless, you must set the Frequency of treatment.

Treatment to be provided - All Insurance Types

If you want to include custom information in the Treatment to be provided section, use the Other checkbox in the Specialties section.                      

The Billing section contains speech-related CPT codes. Select the codes related to the treatment you provided. Be sure to follow the 8-minute rule when billing Medicare insurances. When ready to finalize, click Preview and Finalize. The system will check that all required fields are completed and will alert you to any issues that need to be corrected before finalization.

Finalization 

When the note is finalized successfully two entries appear in the Records section of the patient's chart. The Initial Examination note, and a Daily Note which contains the billing sheet from the IE.

Continuing Treatment

Subsequent treatment documentation can be completed following WebPT Documentation practices. Because many of the fields entered in the Initial Examination carry forward to subsequent documentation, many of these required fields will already be populated in your next note. Remember to adjust these values as needed. Use daily notes for standard visit documentation. Use progress notes every tenth visit or if the patient presents with a significant change in symptoms. Finally, use the appropriate discharge note to complete patient treatment.