Professional Development Corner: Documentation – A Valuable Lesson

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[Source:  The Speech and Language Connection]

documentation

If you had emergency surgery overnight and couldn’t go back to work for several weeks, would another clinician be able to look at your notes and pick up where you left off? Will they read your goals/objectives and know exactly what you were planning to address?  If someone had to update your goals and objectives for you, would they be able to do so by looking at your notes?

Probably not.

As much as we are data driven, we don’t always take the best data. Yes, we take some sort of data but how thorough is it? We have the date, time, and activity we did when we saw our client/student but what did you write after that?

Public school SLPs are normally back to back with students. We write down what we did with our students or why they weren’t seen and have the best intentions to go back to our notes and write down what actually happened in therapy, but we don’t.  Who plans ahead and thinks of the “what ifs?” I didn’t, but I do now.

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