In North Carolina public schools, each speech-language pathologist seems to have evolved with his or her unique method of treatment data collection, and I'm no different. But when I started in the schools, I really had no system—after all, data collection and paperwork tracking weren't taught in my pre-technology-revolution graduate school days.
However, when schools began to seek reimbursement from Medicaid for speech-language services, it soon became apparent that I needed to get paperwork savvy. After attending several trainings on the documentation needed for Medicaid, I started to tighten up.
My true moment of transformation happened when I heard a story about another SLP who was literally escorted out of the school for her lack of a data collection system—as in, she had no system—all the while billing Medicaid. In case readers are wondering, that's known as Medicaid fraud. The effect of Medicaid documentation on school SLPs has been immense—details such as minutes per session, group size, location of session, list of skilled interventions and amount of progress per session all need to be documented for each student for each session.
My mental light bulb has lit up, and what you see below is what I share with my graduate student interns about documentation. Taking these steps ensures that if I were ever taken to court, I could say that I have done my best in reporting a child's progress, or lack of progress, on individualized education program goals.
- The backbone of my system is an old-fashioned paper document. When a new child with an IEP is added to my caseload, I type up a therapy note form from a template in Microsoft Word that contains the goals/objectives and pertinent information such as diagnosis codes, date of birth, setting for speech services and IEP dates. I've custom-made my forms to fit my students' needs and my documentation style. However, there are countless examples of other data forms available on the web. For example, SLP Lisa Varo provides numerous links to forms on her Pinterest site. Whatever works for an SLP and the school system is good, as long as it provides enough information for documenting progress and meeting Medicaid requirements.
- For each session, I give myself room to write the activities, skilled interventions, objective data, amount of progress and a signature. For years, this is the form I've used to record therapy data by hand. Read on, though! What I do now is type data into customized Google forms, which are based on the therapy note forms.
- After completing a therapy note document, I create a Google form based on the same information. Google forms and spreadsheets are effective, easy ways to collect and display both objective and anecdotal data. I have a tutorial for creating forms on my site.
- After each session, I open the student's Google spreadsheet, open a "live" form, and input all of that session's data. I find with this method, I record more detailed information, and the typed document is cleaner and easier to read. Simple graphs can easily be created for some of the data I've collected over several sessions.
Even if I do use a Google form for data collection, I still need to sign for each session (on my original paper document) so I print and staple the Google spreadsheet to my signed forms. I don't record the data twice except for the dates of the sessions. (The paper documents are relatively blank except for the words "see Google form" in the data and activities spaces).
At IEP progress report time, these Google spreadsheets have been invaluable in seeing student growth over the course of each quarter. A couple of times this year, these spreadsheets have also been helpful when parents have asked to see my session notes.
Our special education program still requires paper documents and signatures, so as stated earlier, the paper form remains integral for documentation. The Google form, however, contains the substance of what I do in treatment with each student.