For example, some payers like Medicaid and Medicare will require the total treatment time listed on the note. In addition to medical necessity and skilled intervention, it’s also important to check the requirements and regulations of the payer with whom you’re working. We must answer the question, why did this client benefit from seeing a speech-language pathologist? Most importantly, SLPs must document medical necessity and skilled intervention. If your private practice offers superbills to your private pay clients, some of those payers may ask you for additional documentation before they reimburse the client. You want to protect yourself from an audit, and keep track of your work with your clients so you can track progress or change directions when necessary.Įven if you don’t accept insurance, your clinical documentation must still be defensible. Whether you are paneled with insurance companies or private pay only, you must document your sessions. A session note can be written in different forms, and SOAP notes are the most commonly used form. Speech-language pathologists are required to demonstrate skilled intervention and progress for clients. Each note follows the same structure, and all your information is clearly laid out in digestible parts for you-or another provider-to revisit and know exactly what’s going on in a client’s treatment plan. The Subjective, Objective, Assessment, and Plan (SOAP) note is a commonly used note template across healthcare fields, so you can easily standardize your note-taking process and share it with other practitioners if needed. What is a SOAP Note in Speech-Language Pathology? SOAP notes are one great way to standardize your note-taking and streamline your paperwork at the end of a long day of sessions. As you grow in your career, you’ll find a rhythm for documenting the most important elements of your speech therapy sessions that works for you. Doing paperwork and taking notes might not be your favorite part of your job as an SLP-but it’s a necessary one.
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