Speech Therapy NotesSLP Documentation Guide
Complete guide to speech-language pathology documentation including SOAP notes, evaluations, progress reports, and discharge summaries. With real examples, templates, and insurance-compliant strategies.
Effective SLP Documentation
Speech-language pathology documentation must demonstrate skilled intervention, measurable progress, and medical necessity. Whether documenting articulation therapy, language treatment, fluency intervention, or dysphagia management, your notes should clearly show how SLP services address functional communication goals.
Quality SLP documentation includes specific data (accuracy percentages, cue levels), links progress to functional outcomes, and justifies the need for continued skilled services. This guide provides templates and examples for all types of SLP documentation.
AI documentation tools like PatientNotes can help SLPs reduce note-writing time by automatically capturing session details and generating formatted SOAP notes, letting you focus on therapy rather than paperwork.
SLP Treatment Domains
Documentation requirements vary by treatment domain. Here's what to track for each area.
Articulation/Phonology
Speech sound production and phonological patterns
- • % accuracy by position
- • Phonological process elimination
- • Intelligibility %
- • Produce target sound in isolation/words/sentences
- • Eliminate phonological processes
Language (Receptive)
Understanding spoken language
- • Standardized test scores
- • Following directions accuracy
- • Comprehension %
- • Follow X-step directions
- • Answer WH questions
- • Identify vocabulary
Language (Expressive)
Verbal expression and formulation
- • MLU
- • Sentence complexity
- • Narrative skills
- • Use X-word sentences
- • Retell stories
- • Describe pictures
Fluency
Stuttering and fluency disorders
- • % syllables stuttered
- • Severity rating
- • Secondary behaviors
- • Reduce disfluencies
- • Use fluency strategies
- • Reduce avoidance
Voice
Vocal quality, pitch, loudness
- • Perceptual ratings (GRBAS)
- • Acoustic measures
- • Self-rating
- • Reduce vocal strain
- • Achieve appropriate pitch/loudness
- • Vocal hygiene
Swallowing (Dysphagia)
Feeding and swallowing function
- • Diet level
- • Aspiration status
- • FOIS score
- • Advance diet texture
- • Use compensatory strategies
- • Reduce aspiration risk
Cognitive-Communication
Communication affected by cognition
- • Attention tasks
- • Memory recall
- • Executive function
- • Improve attention to task
- • Recall information
- • Problem-solve
AAC
Augmentative and alternative communication
- • Device proficiency
- • Communication rate
- • Independence
- • Navigate device
- • Generate messages
- • Communicate basic needs
SLP Documentation Templates
Comprehensive templates for all types of speech-language pathology documentation.
Initial Evaluation Report
Comprehensive assessment establishing communication baseline and treatment recommendations.
Required Elements:
Example:
SPEECH-LANGUAGE PATHOLOGY INITIAL EVALUATION Date: 12/18/2024 Clinician: Jennifer Adams, M.S., CCC-SLP PATIENT INFORMATION: Name: Ethan Miller DOB: 03/15/2019 (Age: 5;9) Diagnosis: Speech Sound Disorder (F80.0) Referral Source: Dr. Sarah Chen, Pediatrics Reason for Referral: Unintelligible speech, difficulty with /r/, /s/, /l/ sounds BACKGROUND INFORMATION: Ethan is a 5-year-9-month-old male referred for speech-language evaluation due to concerns about speech intelligibility. Per parent report, Ethan's speech is understood by family approximately 70% of the time and by unfamiliar listeners approximately 50% of the time. Medical History: Unremarkable. No history of ear infections. Hearing screening passed 10/2024. Developmental History: Motor milestones met within normal limits. First words at 12 months, two-word combinations at 24 months. History of speech therapy ages 3-4 (early intervention), discharged due to age out. Family History: Older sibling received speech therapy for articulation. No other communication disorders reported. ASSESSMENT RESULTS: Oral-Motor Examination: - Structure: WNL for lips, tongue, teeth, palate - Function: Adequate ROM for speech; mild tongue protrusion during /s/ production - Diadochokinetic rates: WNL for age Standardized Testing: Goldman-Fristoe Test of Articulation-3 (GFTA-3): - Standard Score: 72 (Below Average) - Percentile Rank: 3rd - Errors: /r/ (all positions), /s/ (all positions), /l/ (blends), /θ/ (initial) Khan-Lewis Phonological Analysis-3 (KLPA-3): - Phonological processes present: Gliding (/r/→/w/), Fronting (/θ/→/f/), Cluster reduction Clinical Assessment of Articulation and Phonology (CAAP): - Consonant Inventory: Missing /r/, inconsistent /s/, /l/ - Stimulability: /s/ stimulable at isolation; /r/ minimally stimulable Language Screening: - CELF-5 Screening: Passed - Receptive/expressive language skills appear WNL Intelligibility: - Single words: 75% - Connected speech: 60% - Contextual speech: 50% CLINICAL IMPRESSIONS: Ethan presents with a moderate speech sound disorder characterized by multiple articulation errors affecting intelligibility. Primary concerns include: 1. Substitution of /w/ for /r/ in all positions (gliding) 2. Distortion/substitution errors on /s/ (frontal lisp pattern) 3. Cluster reduction affecting /l/ and /r/ clusters Speech errors are negatively impacting academic participation (per teacher report) and social interactions (per parent). Ethan demonstrates frustration when not understood. Prognosis: Good, given age-appropriate language skills, good oral-motor function, stimulability for /s/, motivation, and family support. RECOMMENDATIONS: Speech-language therapy is recommended to address speech sound production. Recommend individual therapy 2x weekly for 30-minute sessions. TREATMENT GOALS: Long-Term Goals (6 months): 1. Ethan will produce /s/ in all positions of words with 90% accuracy in structured tasks 2. Ethan will produce /r/ in initial and final positions with 80% accuracy 3. Speech intelligibility will increase to 80% in connected speech Short-Term Goals (8 weeks): 1. Ethan will produce /s/ in isolation with 90% accuracy 2. Ethan will produce /s/ in initial position of words with 80% accuracy 3. Ethan will identify correct vs incorrect /r/ productions with 80% accuracy 4. Ethan will produce /r/ in isolation with tactile cues with 70% accuracy Parent conference completed. Treatment plan discussed and agreed upon. _______________________________ Jennifer Adams, M.S., CCC-SLP License #: SLP-12345
Daily Treatment Note (SOAP)
Session-by-session documentation of treatment provided.
Required Elements:
Example:
SPEECH-LANGUAGE PATHOLOGY TREATMENT NOTE Date: 12/18/2024 | Time: 3:30 PM | Duration: 30 min Clinician: Jennifer Adams, M.S., CCC-SLP Patient: Ethan Miller | DOB: 03/15/2019 Dx: Speech Sound Disorder | Session: 8 of 24 SUBJECTIVE: Mom reports Ethan has been practicing /s/ words at home using the word cards. States his teacher commented that his speech seems clearer. Ethan expressed excitement about earning stickers for his progress chart. Denies illness or concerns. OBJECTIVE: Goals Addressed: 1. /s/ production in initial position of words (Target: 80%) 2. /s/ production in final position of words (Target: 70%) Activities & Performance: Activity 1: /s/ Word Drill - Initial Position (10 min) - Target words: sun, soap, sock, sand, seed (20 trials) - Accuracy: 17/20 (85%) - GOAL MET - Cues needed: Visual model 2x, placement reminder 1x - Self-corrections: 2/3 errors Activity 2: /s/ Word Drill - Final Position (10 min) - Target words: bus, house, mouse, dress, class (20 trials) - Accuracy: 14/20 (70%) - AT GOAL - Cues needed: Tactile cue (tongue placement) 4x - Pattern: Errors increased with multisyllabic words Activity 3: /s/ in Carrier Phrases (10 min) - Carrier phrase: "I see a ___" (initial /s/ words) - Accuracy: 12/15 (80%) - Spontaneous carryover noted to "I see" productions Materials Used: Articulation cards, mirror, sticker chart, iPad app (Articulation Station) Behavioral Observations: - Attention: Good, engaged throughout - Participation: Enthusiastic - Awareness: Improving self-monitoring; corrected 2 errors independently Home Practice Assigned: - Practice /s/ final position words 5 min daily - Read provided word list with parent ASSESSMENT: Ethan continues to make excellent progress on /s/ production. Initial position /s/ goal met (85%); ready to progress to phrase level. Final position /s/ at target level but requires more practice before advancement. Self-monitoring skills improving. Recommend continuing current treatment frequency. Goal Progress: - STG 1 (/s/ isolation 90%): MET (100%) - STG 2 (/s/ initial 80%): MET (85%) - STG 3 (/r/ identification 80%): Progressing (75%) - STG 4 (/r/ isolation w/cues 70%): Progressing (60%) PLAN: Continue speech therapy 2x/week per POC Next session: - Progress /s/ initial to phrase/sentence level - Continue /s/ final position at word level - Introduce /r/ production activities - Update home practice materials _______________________________ Jennifer Adams, M.S., CCC-SLP
Progress Report
Periodic summary of progress for insurance and treatment planning.
Required Elements:
Example:
SPEECH-LANGUAGE PATHOLOGY PROGRESS REPORT Date: 01/29/2025 Clinician: Jennifer Adams, M.S., CCC-SLP Patient: Ethan Miller | DOB: 03/15/2019 Dx: Speech Sound Disorder (F80.0) Treatment Period: 12/04/2024 - 01/29/2025 Sessions Attended: 12 of 12 (100%) SUMMARY OF TREATMENT: Individual speech therapy provided 2x weekly focusing on /s/ and /r/ articulation using traditional articulation therapy approach, phonological awareness activities, and home practice program. PROGRESS TOWARD GOALS: | Goal | Baseline | Current | Status | |------|----------|---------|--------| | /s/ isolation 90% | 60% | 100% | MET | | /s/ initial words 80% | 50% | 90% | MET | | /r/ identification 80% | 40% | 85% | MET | | /r/ isolation w/cues 70% | 20% | 75% | MET | CURRENT PERFORMANCE: /s/ Sound: - Isolation: 100% (mastered) - Initial position words: 90% - Final position words: 85% - Initial position sentences: 80% - Conversational carryover: Emerging (50%) /r/ Sound: - Isolation (with visual/tactile cues): 75% - Initial position words: 40% (newly introduced) - Stimulability significantly improved Intelligibility: - Connected speech: 75% (↑15% from baseline 60%) - Per parent: "People understand him much better now" CLINICAL IMPRESSIONS: Excellent progress on all initial goals. /s/ production has improved significantly and is approaching mastery at the sentence level. /r/ stimulability has improved dramatically; patient now producing accurate /r/ in isolation. Self-monitoring skills have developed well. Parent reports functional improvement in classroom participation. REVISED GOALS (Next 8 weeks): Short-Term Goals: 1. Ethan will produce /s/ in sentences with 90% accuracy 2. Ethan will demonstrate /s/ carryover in structured conversation with 70% accuracy 3. Ethan will produce /r/ in initial position of words with 70% accuracy 4. Ethan will produce /r/ in final position of words with 60% accuracy Long-Term Goals: 1. /s/ carryover to spontaneous speech at 80%+ accuracy 2. /r/ production at word level in all positions at 80%+ accuracy 3. Speech intelligibility 90% in connected speech RECOMMENDATIONS: Continue speech therapy 2x weekly. Patient responding well to treatment approach. Continued skilled services required to achieve carryover and address /r/ production. Anticipate discharge in approximately 12-16 additional sessions pending progress. Medical Necessity: Continued skilled SLP services required. Patient has not yet achieved carryover to conversational speech. Ongoing errors continue to impact academic participation and social communication. _______________________________ Jennifer Adams, M.S., CCC-SLP License #: SLP-12345
Discharge Summary
Final documentation upon completion of speech therapy services.
Required Elements:
Example:
SPEECH-LANGUAGE PATHOLOGY DISCHARGE SUMMARY Date: 04/16/2025 Clinician: Jennifer Adams, M.S., CCC-SLP Patient: Ethan Miller | DOB: 03/15/2019 Dx: Speech Sound Disorder Treatment Period: 12/04/2024 - 04/16/2025 Total Sessions: 32 REASON FOR DISCHARGE: Goals met. Patient achieved functional communication and age-appropriate speech intelligibility. TREATMENT SUMMARY: Ethan received individual speech-language therapy 2x weekly for 4 months targeting articulation of /s/ and /r/ phonemes using traditional and phonological approaches with home practice program. GOAL OUTCOMES: | Goal | Baseline | Discharge | Status | |------|----------|-----------|--------| | /s/ in conversation 80% | 50% | 95% | MET | | /r/ in all positions 80% | 20% | 85% | MET | | Intelligibility 90% | 60% | 95% | MET | DISCHARGE STATUS: Articulation: - /s/: Mastered in all contexts including conversation - /r/: 85% accuracy in connected speech (age-appropriate) - /l/ clusters: Resolved - /θ/: Self-corrected (developmental) Intelligibility: - Connected speech: 95% (baseline: 60%) - Teacher report: "No longer stands out from peers" - Parent report: "Strangers understand him easily now" Standardized Testing (Re-evaluation): - GFTA-3: Standard Score 94 (Average range) - Improvement: 22 standard score points HOME MAINTENANCE PROGRAM: Provided written home program: 1. Continue modeling correct productions at home 2. Gentle correction of remaining /r/ errors in reading 3. Praise clear speech 4. Return for re-evaluation if regression noted RECOMMENDATIONS: 1. Discharge from speech therapy - goals met 2. No further treatment needed at this time 3. Monitor at school - contact SLP if concerns arise 4. Re-evaluate in 6-12 months if regression or new concerns PROGNOSIS FOR MAINTENANCE: Excellent _______________________________ Jennifer Adams, M.S., CCC-SLP License #: SLP-12345
SLP Documentation Best Practices
Follow these guidelines to ensure your documentation supports reimbursement and demonstrates the value of speech therapy services.
Include Data
Every session note should have objective data - percentages, accuracy ratios, cue levels. "80% accuracy with minimal cues" is better than "did well."
Show Skilled Care
Document why SLP services are necessary. What clinical reasoning, specialized techniques, or expertise did you apply?
Track Progress Toward Goals
Every note should reference established goals with current performance data. Show movement toward (or barriers to) goal achievement.
Document Cue Hierarchy
Specify cues provided: independent, verbal, visual, tactile, model. Cue reduction over time demonstrates progress.
Note Functional Impact
Connect treatment to real-world communication. How does progress in therapy translate to classroom, home, or work performance?
Include Carryover Data
When relevant, document performance differences between structured tasks and spontaneous communication to justify continued treatment.
Frequently Asked Questions
What is a speech therapy SOAP note?
An SLP SOAP note is a structured documentation format using Subjective (patient/caregiver report), Objective (session data and measurements), Assessment (clinical analysis), and Plan (future treatment direction) to record speech-language pathology sessions.
What should be included in speech therapy documentation?
SLP documentation should include: communication goals addressed, specific activities/techniques used, patient performance data (accuracy percentages, cues needed), progress toward goals, and plan for next session. Medical necessity must be clear.
How do you document speech therapy goals?
SLP goals should be SMART: Specific (target skill), Measurable (accuracy %), Achievable (realistic), Relevant (functional communication), and Time-bound (target date). Example: "Patient will produce /s/ in initial position with 80% accuracy in 8 weeks."
What billing codes do SLPs use?
Common SLP CPT codes include: 92507 (speech treatment), 92508 (group treatment), 92521-92524 (evaluation codes), 92526 (swallowing treatment), and 97530 (therapeutic activities). Documentation must support the billed code.
Can speech therapy assistants (SLPAs) write treatment notes?
SLPAs can document treatment sessions they provide under supervision. However, evaluations, diagnostic reports, and treatment plan modifications must be completed by the supervising SLP. SLPA notes should indicate supervision status.
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