All students services (e.g., treatment/session data, daily notes, SOAP notes) will be documented using a data sheet of some form.
Key information contained in service documentation:
IDC10 Code List - Speech Language Codes are on the second page at the bottom
SOAP Note - brief synopsis of treatment activity (1-2 sentences), how the student performed and level of support given (e.g., hard data once a month), what will be addressed next session given the students performance
Sample Service Documentation on Progress tab:
The student participated willingly in the speech session and was actively engaged throughout. During the session, the group worked on a language-based literacy activity. With several verbal, visual, and tactile cues, the student produced the "r" sound at the beginning of words with about 60% accuracy. The student also practiced using the past tense "ed" in fill-in-the-blank exercises and when retelling a story, achieving approximately 45% accuracy with visual cues. Additionally, the student independently answered who, what, and where questions about the narrative with around 65% accuracy. In the next session, we will continue to focus on correctly producing the /r/ sound to improve speech clarity, as well as enhancing the use of targeted grammatical structures and wh- questions.
Services provided by the Speech Language Pathologist for student's who are Medicaid eligible will be documented in Enrich and copied into ezEdMed.