Clinical Documents Progress Reports

General Characteristics Usually cover one month of therapy Usually cover 6-8 sessions Audience is wider than that of clinical notes Includes two signatures at end: the clinician and the supervisor

Basic Parts of the Progress Report Identifying Information Background Information Baseline Testing Client’s Motivation Frequency of Speech-Language Services Long-term Goals Short-term Goals Results Summary of Achievement Recommendations

Identifying Information “Vital Statistics” about the client Include all information needed Use proper format for order and spacing

Background Information Name, age, and sex of client usually in first sentence Purpose of referral History of previous therapy Developmental milestones (child) Home, work, school environments Birth and medical history, if appropriate Current therapy

Baseline Testing Results of tests given prior to therapy Include dates of tests Use tables, paragraphs, lists Write in past tense

Client’s Motivation Behavior and attitude during therapy Record of homework completion (if applicable)

Frequency of Speech-Language Services Number of sessions attended during the period covered by the report Number of sessions cancelled and for what reason Number of tardies Time and days of the week that therapy took place

Long-Term Goals Goals that will take months/years to achieve Cover broad achievements such as increasing reading abilities to a certain grade level Name client and use future tense

Short-Term Goals Can be achieved in a relatively short time Are usually very specific, as opposed to broad Use client+target+criterion format Include a procedure paragraph after the short-term goals

Results Use table format Report a result for every short-term goal attempted during the time period covered by the report

Summary of Achievement Assess the client’s performance of the short-term goals (what has been mastered and what will need additional practice?) General statements concerning overall progress toward long-term goals are sometimes included

Recommendations Describe plans for future therapy based on the assessment Include any new short-term goals Include any recommended strategies or procedures Indicate frequency and duration of future therapy