Copy and Paste Progress Notes During Coronavirus for Speech-Language Professionals

Copy and Paste Progress Notes

for Speech-Language Pathologists and Professionals During COVID-19

How to Write Progress Notes for Speech-Language Therapy During Coronavirus Pandemic

Feeling stressed about how to write up report cards and progress notes right now? We’ve had a few of our members in The SLP Solution membership asking about how they should write progress notes for their clients when therapy has been affected so much by the Coronavirus pandemic during the last reporting period.

We figured that our members weren’t the only ones wondering this! And since we’re all about saving you time, here’s some sample text that you can copy and paste into your progress reports for your next progress reports. Feel free to grab and use whichever pieces of this you need!

***NOTE: Please replace the word “CLIENT” with your client’s name and customize all text to be specific to your client and your situation.

Introduction:

Services during this reporting period were affected by the novel Coronavirus pandemic. CLIENT received the following services during this reporting period:

START DATE OF REPORTING PERIOD – LAST DATE OF NORMAL SERVICES: CLIENT received services in-person, as per the usual plan.
DATES OF INTERIM (WHEN NEW SERVICES WERE BEING ESTABLISHED): The clinic/school was closed due to Coronavirus and no services were provided during this time as alternative methods were being established.
FIRST DATE OF IRREGULAR SERVICES: <Describe the specific situation – use text from the box below>

Sample Text for Describing Situation:

If no services/contact: Direct services were not conducted during this time period. No contact was made between client/family and the therapist. The school/clinic was closed due to Coronavirus and therapy was not able to be maintained due to limitations of technology, scheduling, and communication difficulties.
If no services but communication was maintained: Direct services were not conducted during this time period. The school/clinic was closed due to Coronavirus so therapy could not continue, but the therapist was able to maintain contact with the client/family and provide support via phone calls.
If no services but home activities were sent: Direct services were not conducted during this time period. The school/clinic was closed due to Coronavirus so therapy could not continue, but the therapist was able to send home activities and ideas to help parents continue to support speech/language development at home.
If teletherapy services were conducted: Direct services were not conducted during this time period. The school/clinic was closed due to Coronavirus and direct services were conducted via teletherapy/telemedicine. Services were conducted with the following frequency: <INSERT FREQUENCY OF TELETHERAPY SERVICES DELIVERED>.

Pre-Coronavirus Progress:

Prior to the school/clinic closure, CLIENT was working on the following goals during speech/language therapy. The percentages below represent CLIENT’S progress before the closure:

GOAL: ACCURACY (example: Produce /s/ in syllables: Accuracy before closure – 65%)
GOAL: ACCURACY (example: Use pronouns “he” and “she” in sentences: Accuracy before closure -75%)

Post-Coronavirus Progress:

<Choose the scenario that best fits the situation>

If no services or contact:
Since there has been no communication with the client/family since the date of closure, it is unclear whether the client has maintained these skills since the last date that data was collected. It is important to note that during this time, everyone has been under a tremendous amount of stress. School/business closures have created disruptions in schedules and routines and many people have experienced financial hardships. Stress levels have been high with worries about health, financial stability, and availability of resources. Increased stress can make it more difficult for individuals to learn new skills and clients may even regress on skills previously acquired. CLIENT’s communication skills and abilities should continue to be monitored and re-evaluated when it is safe and appropriate to resume services.

If no services but have had communication:
Since the closure of the school/clinic, CLIENT/FAMILY MEMBER has reported the following update on CLIENT’s skills. <INSERT NOTES FROM CAREGIVER ABOUT PROGRESS OR REGRESSIONS>

It is important to note that during this time, everyone has been under a tremendous amount of stress. School/business closures have created disruptions in schedules and routines and many people have experienced financial hardships. Stress levels have been high with worries about health, financial stability, and availability of resources. Increased stress can make it more difficult for individuals to learn new skills and clients may even regress on skills previously acquired. CLIENT’s communication skills and abilities should continue to be monitored and re-evaluated when it is safe and appropriate to resume services.

If no services but home activities were sent:
Since the closure of the school/clinic, activities have been sent home for CLIENT to practice. CLIENT/FAMILY MEMBER has reported the following update on CLIENT’s skills after receiving these activities. <INSERT NOTES FROM CAREGIVER ABOUT PROGRESS OR REGRESSIONS>

If teletherapy services were provided:
Since the closure of the school/clinic, teletherapy services have been provided. CLIENT has been working on the following goals during speech/language teletherapy. The percentages below represent CLIENT’S progress after engaging in teletherapy services:

GOAL: ACCURACY (example: Produce /s/ in syllables: Accuracy after teletherapy – 65%)
GOAL: ACCURACY (example: Use pronouns “he” and “she” in sentences: Accuracy after teletherapy -75%)

It is important to note that during this time, everyone has been under a tremendous amount of stress. School/business closures have created disruptions in schedules and routines and many people have experienced financial hardships. Stress levels have been high with worries about health, financial stability, and availability of resources. Increased stress can make it more difficult for individuals to learn new skills and clients may even regress on skills previously acquired. CLIENT’s communication skills and abilities should continue to be monitored as this situation progresses and supports should continue to be provided with the consideration that CLIENT’s needs may change over the coming months.

Further Considerations:

That should be enough to get you going on your progress notes. But you may want to consider including a few other things in your progress notes:

Specific information you know about the client’s specific situation, such as living situation, loss or illness of loved ones, or other stressors. These will be helpful for someone reading this later to understand the bigger picture of the client’s life.
Plan for continued therapy: What will happen now? Is there a plan in place for the client to receive services in the coming months?
Missed Services: If you have missed therapy time that legally must be made up, you may want to ask your administrator if you need to include how many minutes have been missed. Check with your admin before you write this.

Need More Help?

Do you need more support as a speech-language pathologist or professional? We’d love to have you join our membership! You’ll be able to access all of our resources on conducting teletherapy and our digital resources and curriculum.