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How to Create a Speech Therapy Observation Report Using My EMR

Reading Time: 7 Minutes

We explain how an intuitive, easy-to-use EMR solution can streamline your entire report-writing process

Besides direct clinical work, writing a speech therapy observation report is one of the foundational skills of any SLP.

Whether it’s for parents, caregivers, payers, referrers, or other clinicians, you’ll often need to write a report to communicate your assessment and recommendations about a client. 

But like client notesreport writing can be very time-consuming. 

Without a good system in place for collecting information and generating a report, the process can take much longer than necessary, resulting in a loss of valuable clinical time and unnecessary stress for the practitioner.

However, with the right EMR, report writing doesn’t have to be a challenge.

In this article, we’ll detail how a good EMR can make report writing faster and easier, beginning with an overview of what a speech therapy observation report is. 

What Is a Speech Therapy Observation Report?

In a general sense, a speech therapy observation report is exactly what it sounds like: A formal report written by a speech therapist that details observations and assessment of a patient in a particular situation. 

There is no single standard or structure for observation reports in speech therapy. But the style of each report is usually heavily influenced by the setting the therapist is working in and the purpose of the report. 

For example, an observation report of a stroke patient in a skilled nursing facility is likely to be quite different from one for a 5-year-old in an early childhood setting. And in both these cases, the audience and purpose of the report will influence the style as well.

In the case of the 5-year-old, a speech therapy observation report to give parents or caregivers strategies to support language development, would be laid out quite differently to a report for insurance purposes. 

Below are some common settings where observation reports are utilized by speech therapists, followed by a list of topics that are often addressed.

Common Settings for Observation Reports

Observation reports tend to be mainly used in situations where a patient has difficulty giving a clear account of their symptoms and challenges due to age or cognition.

For example, a speech therapist might observe:

  • A young child at play or when interacting with their family
  • An elderly patient with dementia and swallowing difficulties during mealtime
  • A teenager with autism while undertaking daily activities with caregivers
  • People of any age who have suffered a stroke or acquired brain injury during tasks such as talking with family and friends, or making a phone call 

During the observation, the therapist would generally take notes. Or as is more common nowadays, the entire session can be recorded by video (with appropriate consent).

After observing, a report is written to detail the speech therapist’s assessment, insights, and recommendations.  


Looking for more free resources for your practice? We have a point-of-care documentation guide for therapists on-the-go.


Topics Often Addressed in a Speech Therapy Report

As already discussed, the exact content of a speech therapy observation report will depend on the purpose of the report. But some topics that are commonly covered in most settings and situations.

In general, as speech therapy observation report will include:

Patient name, demographics, and a summary of the presenting problem

For example, “Max is a 7 year old boy with language delay due to verbal dyspraxia.”

A short statement about the purpose of the report

“Max’s teacher and parents requested an assessment to provide recommendations of strategies to assist with language development in the classroom and at home.” 

Description of the event being observed

Observation took place for 1 hour during class at Max’s school on 3rd March 2023. Max was also observed with his parents during a free-play and reading session of 45 minutes in the clinic on 10th March 2023.”

Key insights and observations

List and describe all important observations from the session(s), such as:

  • Receptive and expressive language
  • Attention and listening
  • Communication skills
  • Non-verbal communication
  • Fluency and tone

Assessment (formal and/or informal)

Make note of any formal assessment tools that have been completed and describe the results. Give an assessment of the situation, including a diagnosis of the problem if appropriate. 

Recommendation

Give a recommendation based on your observations, assessment, and clinical judgment. It’s fine to include several recommendations, just be sure to address the specific purpose of the report.

Why Observation Reports Are Important

Speech therapy observation reports are an important source of formal communication between the therapist and other involved parties. 

Depending on the situation, a speech therapy observation report might:

  1. Result in an insurer approving a course of therapy for a patient
  2. Provide vital education and information to caregivers
  3. Make a formal diagnosis or give an expert opinion
  4. Outline a treatment and rehabilitation regime (either stand-alone or as part of a multi-disciplinary approach)
  5. Give a comprehensive overview of a person’s communicative strengths and weaknesses

Common Challenges with Report Writing

By far, the biggest challenge with writing a speech therapy observation report is the time creating the report takes.

At a minimum, writing a report involves:

  • Reviewing the referral and background information
  • Gathering collateral from the client, referrer, and/or caregivers
  • Scheduling and planning the session
  • Completing the observation (may require more than one session)
  • Conducting any testing or assessments required for the report
  • Writing the speech therapy observation report
  • Sending the report and answering any queries
  • Completing any follow-up tasks

With this many moving parts, clinicians stand no chance of completing an observation report without a rock-solid system in place. Such a system helps ensure the entire process runs as smoothly and efficiently as possible.

Fortunately, with the help of the right EMR, you can streamline many of the steps in completing a speech therapy observation report.  

How an EMR Helps Create Speech Therapy Observation Reports

A good EMR, like Fusion, is capable of providing end-to-end support and assistance with the creation of speech therapy observation reports.

Fusion is a simple but full-featured EMR solution designed specifically for speech therapists, PTs, and OTs. It’s made by therapists, for therapists, so you can be assured that the platform is designed to improve your efficiency and the quality of care you deliver.

On a broad level, the software allows clinicians to utilize streamlined systems and pathways that cover everything involved in writing a report, from intake and scheduling, to assessment and report creation, and even communication with stakeholders.

At each stage, you can use the ready-made templates in Fusion as is, or customized to your exact needs.

For example: 

  • Need to include a specific language or swallowing assessment in your session? No problem. Just add it to the observation template.
  • Have a questionnaire you’d like clients and caregivers to complete before the observation? Make it available through our secure client portal, so it can be completed and submitted online.
  • Want a checklist to ensure you’re efficiently moving through every step of the report creation process? You can create custom workflows to keep you and your team on track. From the point of receiving a referral for a speech therapy observation report to completing follow-up tasks, every step can be documented and standardized.
  • Sick of having to spend ages pulling together all the information you need to write a report? With Fusion, when it comes time to write, every piece of information you need to write a speech therapy observation report will be at your fingertips. Many of the details can even be set to auto-populate on your chosen report template.
  • Worry that you won’t remember what to take note of in the observation session? Use a customizable template to ensure you cover all the essential components that need to go into your report.

Make Report Writing Easier

Report writing might not be the most enjoyable part of being a speech therapist. But remember, a well-written speech therapy observation report can be life-changing for your client.

Getting payer approval for therapy. Making a diagnosis for a child struggling with language delay. Giving parents and caregivers actionable advice to reduce stress and provide better care. These are all things that can really move the needle in a positive way for your clients. Often in a different, yet complementary way to 1:1 clinical support.

So to deliver the best care to your clients, while reducing your stress levels, give Fusion a try today. 

Our intuitive and customizable EMR solution for speech therapists, PTs, and OTs includes everything you need to streamline observation report writing, and operate your entire practice, all in one place.

To find out how Fusion helps you work smarter, not harder—book a demo now.

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