Paperwork

The clinic requires we keep paperwork for each client. Some documents need to be completed for every session,  others only happen once a semester. Below are the documents you will need to become familiar with reading and writing over the course of your clinical experience. 

Session plans are completed before each session; they are your plan and list your expected goals, activities, and your rationale. Lesson plans are not kept in the client's file.

SOAP Notes are summaries of your sessions. They explain your goals, how the client preformed, any difficulties or successes of the client, and your plan for the next sessions. A SOAP Note must be added to the client's file for each session that is held. 

Treatment Plans are completed once a semester for each client. They explain the goals that will be targeted over the course of the semester, how the client preformed on those goals at the beginning of the semester, and where you expect them to be at the end. You will also explain any techniques you plan to use and how you plan to run your sessions. Treatment plans must be signed by the client/parent, the clinician, and clinical educator and are kept in the client files. 

End of Semester reports are completed once for each client, before the semester has finished. Similar to a Treatment Plan, EOS reports include the client's accuracy on goals from the beginning and end of the semester as well as an explanation of techniques used that were helpful for the client.  EOS reports must also be signed by the client/parent, the clinician, and clinical educator and are kept in the client files. 

Case presentations are completed at the beginning of the semester, for each client. They include a review of the client's pertinent medical and speech/language therapy, their current goals, and any other information that is important to know about the client. These are typically completed before one of your first meetings with your supervisor so you can discuss your client, the goals you may be working on, and how to approach therapy. Case presentations are not kept in the client files. 

Speech and Language Evaluation Reports are completed by Diagnostics 1 and 11 students after clinic evaluations. Reports are due to the clinic files two weeks after each evaluation. Above is a helpful outline to follow for guidance. Note that evaluation reports may look vastly different depending on a number of factors--nature of evaluation, formal vs. informal measures, client age, etc. 

Confidentiality Agreements must be completed, signed, and returned to a GA before you can observe in the clinic. The second page includes instructions for a HIPPA module that must also be completed. Upon completion, print the certificate and bring it to the clinic for our records.