Speech Therapy Discharge Summary Template and Examples
Updated: April 25, 2024Your patient is ready for discharge, and it's time to prepare a thorough summary of their treatment journey. This article offers tips for crafting quick and accurate discharge summaries, and how using templates and TextExpander can streamline the process and enhance clarity.
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How to Write an Effective Speech Therapy Discharge Summary
Crafting discharge summaries in speech therapy requires details around the therapy techniques provided, patient progress, and recommendations for continued patient success. Here are a few tips to enhance the quality and effectiveness of your discharge summaries:
- Highlight Specific Therapeutic Outcomes: Focus on detailing the specific speech and language goals met and the therapeutic interventions used. For example, if the patient has improved in articulation, be specific about the sounds or words that have seen improvement.
- Document Measurable Progress: Use quantitative measures to describe progress when possible. For instance, note the percentage of correct consonants or the increase in the number of understandable words in spontaneous speech.
- Clarify Remaining Challenges: Identify any ongoing issues or areas that need further attention. This not only helps in setting future therapy goals but also informs subsequent caregivers about areas that require continued intervention.
- Summarize Therapy Techniques Used: Provide a brief overview of the therapy techniques that were most effective for the patient. This can be very helpful for future therapists or continuing practice at home.
Benefits of Using a Speech Therapy Discharge Summary Template
Using templates for speech therapy discharge summaries offer numerous benefits:
- Consistency: Ensures all relevant information is uniformly reported.
- Efficiency: Reduces time spent on paperwork, allowing more time for patient care.
- Accuracy: Minimizes the risk of omitting critical information.
- Professionalism: Maintains a standard of documentation that is professional and easy to understand.
How TextExpander Can Help
TextExpander allows users to create shortcut keys for frequently used phrases and paragraphs. This tool can streamline the creation of speech therapy discharge summaries by ensuring quick, consistent entry of common text segments, reducing typing time, and minimizing errors.
Speech Therapy Discharge Summary Template and Examples
Speech Therapy Discharge Summary Template
Patient Information
– Name
– Date of Birth
– Case Number
Therapy Information
– Date of Initiation
– Date of Discharge
– Type of Therapy Sessions
Assessment and Progress
– Initial Assessment
– Progress and Outcomes
Recommendations and Future Plans
– Follow-up Care
– Home Exercises
Therapist Contact Information
– Name
– Qualifications
– Contact Details
Example 1: Adult Stroke Recovery
Patient Information
– Name: John Doe
– Date of Birth: 01/02/1965
– Case Number: 456789
Therapy Information
– Date of Initiation: 01/03/2022
– Date of Discharge: 12/06/2022
– Type of Therapy Sessions: Individual, bi-weekly, 45-minute sessions
Assessment and Progress
– Initial Assessment: Post-stroke aphasia, moderate severity
– Progress and Outcomes: Expanded vocabulary from 20 to 100 words; improved sentence construction
Recommendations and Future Plans
– Follow-up Care: Continue weekly sessions focusing on conversational skills and reading comprehension
– Home Exercises: Daily vocabulary exercises and reading simple texts aloud
Therapist Contact Information
– Name: Jane Smith, CCC-SLP
– Qualifications: M.Sc. in Speech-Language Pathology
– Contact Details: Email: jsmith@therapyclinic.org, Phone: 555-0123
Example 2: Child Articulation Disorder
Patient Information
– Name: Lucy Brown
– Date of Birth: 05/08/2015
– Case Number: 789012
Therapy Information
– Date of Initiation: 02/04/2021
– Date of Discharge: 30/07/2021
– Type of Therapy Sessions: Individual, weekly, 30-minute sessions
Assessment and Progress
– Initial Assessment: Difficulty with ‘r’, ‘s’, and ‘l’ sounds
– Progress and Outcomes: Achieved clear articulation of ‘s’ and ‘l’; ongoing difficulty with ‘r’
Recommendations and Future Plans
– Follow-up Care: Monitor progress at home, consider re-evaluation in six months
– Home Exercises: Daily practice of ‘r’ sound using word lists and songs
Therapist Contact Information
– Name: Mike Johnson, CCC-SLP
– Qualifications: B.A. in Communicative Disorders
– Contact Details: Email: mjohnson@therapycenter.com, Phone: 555-0456
3: Adolescent Fluency Disorder
Patient Information
– Name: Omar Ali
– Date of Birth: 16/11/2007
– Case Number: 123456
Therapy Information
– Date of Initiation: 10/01/2023
– Date of Discharge: 24/03/2023
– Type of Therapy Sessions: Group sessions, bi-weekly, 60-minute sessions
Assessment and Progress
– Initial Assessment: Moderate stuttering, particularly under stress
– Progress and Outcomes: Improved speech fluency in structured and social settings
Recommendations and Future Plans
– Follow-up Care: Continued practice of fluency techniques; bi-weekly support group meetings
– Home Exercises: Daily fluency exercises; speaking in front of a mirror
Therapist Contact Information
– Name: Emily Carter, CCC-SLP
– Qualifications: Ph.D. in Speech-Language Pathology
– Contact Details: Email: ecarter@speechpathways.net, Phone: 555-0789
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