How to Keep Speech Therapy Data for Teletherapy
I’ve been thinking about how I do my session notes and data collection—what’s worked, what hasn’t, and what I’ll change next year. I thought I’d share some of my thoughts with you today so you can implement what works for you… and I’ll remember next year what I was thinking!
My Current Data Collection System
I have a very simple two-step data collection and documentation system that I’ve used this year.
I keep a spiral notebook at hand that I scribble notes on for each student. I date each page, write down each student’s initials in session order, and jot down the basics of what I need to remember for each session.
At the end of each session or day (preferably), I go into our Medicaid documentation system and type up everything from my notebook in a more coherent form. I’ll admit I’ve been a bit lazy with it this year!
I typically do a sentence about the student’s attention/participation as well as any schedule changes (arriving late, leaving early, etc…), a few sentences about what kind of task we did and the student’s accuracy, a sentence or two with any observations or analysis as needed, and a sentence with any changes to be made for next year. This makes it sound better than it actually is though! Here’s a typical example:
Attended well. Arrived 5 minutes late. Frodo independently identified the irrelevant sentence from a field of 4 after reading a short paragraph during a game. SLP provided action points before game. Said it was mostly easy but some confused him. Continue next week.
In addition to this, I have a Google doc for each school with the student’s goals (and other important information) listed. I began the year planning to fill in a table at the end of each session with percentages, but that never stuck. I do reference this doc during sessions when I need a quick reminder about the specifics of a goal.
What Worked This Year
There are several things that worked well this year!
First, using my spiral notebook is just organized enough and just flexible enough for my ADHD brain! I can easily refer back to my notes if I go a few days without documenting. I won’t change how I keep track of data during the session next year other than organizing my notebook a little bit more—like tabs for each of the different schools.
Second, I really love immediately documenting in one space rather than trying to keep data in a lot of different places like I have in the past. I only began Medicaid documentation last year and I found that I was spending a ton of time collating all of my different systems and documenting properly for reimbursement. I also won’t go back on my primary documentation space being my Medicaid notes.
What Didn’t Work This Year
There are really only a few logistical things that I would change this year!
First, as I mentioned earlier, I would organize my notebook a little bit more. This year, I just wrote everything in the order I did it. There were a few times when that became confusing, such as when I was looking for notes on a specific evaluation or needed to quickly look at something for a specific school. Next year, I’ll use notebooks with tabs and organize by school first then by treatment or evaluation.
Second, I’ll add one step to my Medicaid documentation process. Instead of filling in a chart like I intended to do this year, I’ll copy/paste my Medicaid documentation into my Google doc. I found myself getting annoyed by the arduous process of accessing my Medicaid documentation before and during sessions to check on things from the week before. I think just copying what I’ve already written into a doc that I already access most days will save myself a lot of headaches. Especially when it comes to progress reports!
Lastly, I’ll streamline and organize my actual Medicaid notes a bit better. There are a few things I’ve found myself needing to refer to from my notes that I haven’t always been the best at actually keeping up with! So for next year, I want to create a template that I use in each and every Medicaid note. It’ll take me a little longer to document, but I think my future self will thank me.
Which leads me to…
My Speech Session Note Template for 2025
_____/_____ minutes attended. Notes on missed minutes:
Student’s participation and behavior:
Materials used/tasks implemented:
Student’s performance:
Intervention techniques, scaffolding/cues provided, feedback, etc…
Student’s response to techniques, cues, etc…
Plan’s for next week:
Here’s how that would look in a note based on a session I had this morning:
15/20 minutes attended. Frodo left 5 minutes early due to state testing.
Frodo appeared tired but participated well with no need for redirection.
Completed a Blooket game (Relevant Details)— read a short paragraph (up to 5 sentences) and identified the sentence from a field of 4 that was not relevant to the paragraph.
Frodo completed the task independently with 70% accuracy.
SLP did not provide any intervention strategies during the game but discussed the purpose of the game with action points before the game and discussed his score and perspective after the game was completed. Frodo stated that he thought it was mostly easy but said there were a few that confused him at first and he had to think about more.
Next week, complete a similar task together so the SLP can provide scaffolding as Frodo works.
Compared to the “old version” of this note that I shared earlier, I think this will make it much easier for me to reference when planning the next session and when writing my progress reports.
I’m excited about implementing my new system next year and enjoying the benefits I’m expecting it to generate!
How do you keep data as a teletherapist? Do you have any tips and tricks you swear by? I’d love to hear!
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