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Save Time With These Tips for Making Documentation Easier

by Amanda Rhodes Fyfe
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woman writing report and smiling

woman writing report and smiling

Speech-language pathologists have a pretty sweet gig, am I right? We get to spend our working hours immersed in myriad rewarding tasks like teaching new moms to safely feed their precious babies, helping families learn strategies to communicate with their children and helping people who have had a stroke regain their voices. And when our day of using our communication superpowers for the greater good is through? We get to sit in front of a computer for hours and write about it.

Not in an “I love this work and want to chronicle my experiences” sort of way. More in a “this tedious, painstaking documentation somehow became the focal point of my career” sort of way. Would you like to make it easier? I know I did, so with my partner in crime Sara Adams, I decided to give myself permission to look at the dark side of our profession in a new light.

  1. Consider your audience. For most of us, our primary audience consists of insurance personnel, school administrators and physicians. While they value our expertise, they primarily want diagnostic information, clinical impressions and our recommendations. By streamlining your evaluations through use of bullets and easy-to-read charts, you may make life easier for someone on the receiving end of your report. If you know that another clinician will also treat the patient, include enough information so the other clinician feels confident getting started. Not sure what “enough information” is? If I pick up an articulation student, I like to see a list of sound errors in positions of words and an intelligibility quotient. That’s all I feel I need to plan and initiate treatment.
  2. Don’t re-create the wheel. Daily treatment notes confirm your services can only be provided by a trained SLP. Although the activities you use to target your goals and implement your strategies might change from session to session, the strategies you as an SLP shouldn’t change too much. For example, if you use tactile cueing to increase correct production of /f/, your skilled intervention is always “use moderate tactile cueing in order to establish correct articulatory placement for production of /f/ in all positions of words in order to facilitate increased intelligibility of connected speech for improved communicative efficacy” or something similar. Creating a template of intervention strategies to add to your notes will decrease writing time .
  3. Technology is your (timesaving) friend. Bring your laptop or tablet with you to evaluations. Prep your document with templates prior to settling in with your client for the case history. I understand the fear of seeming cold and detached while taking notes about your client’s concerns, but it’s possible to come across as warm, engaged and efficient. It takes some getting used to, but it beats trying to decipher handwritten notes hours later. I’m not kidding. After one particularly challenging evaluation, I had a piece of paper with about six words on it, none of which related to the previous word.
  4. Work now to relax later. Creating templates of frequently used phrases, test descriptions, tables and outlines saves you a ton of time. Adams saves these as digital post-it notes on her desktop for easy access while drafting reports. Doing the work up front to create these templates significantly reduces your workload later.
  5. Say it with me: Longer does not necessarily mean better. Listen, I get it. I’ve been there. As a novice SLP, I used to agonize over evaluation reports, creating thoughtful lengthy documents rivaling short stories. There’s a time in one’s career to churn out 12-page evaluations—much learning comes from this process—but the sun has set on that time for me. I grew exceedingly comfortable creating concise evaluations with pertinent information and not much else. By all means, incorporate a summary of strengths and weaknesses, but bullet points serve just as well as 14-paragraph write-ups. Your job is to describe the patient’s current level of functioning, strengths and weaknesses, report assessment information and interpretation, create a diagnostic statement, and outline a treatment plan. This is easily accomplished with fewer words, my friends. Trust me.

Do you know other ways to make documentation less time-consuming or more fun? Comment below to share your ideas!

Amanda Rhodes Fyfe, MS, CCC-SLP, works for the Mansfield (Texas) Independent School District. amandafyfe@misdmail.org 

Sara Adams, M.S., CCC-SLP is a pediatric speech pathologist at Cook Children’s Medical Center in Fort Worth, Texas.

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