As a speech pathologist working in the schools, I try to make sure my documentation is thorough and up to date. When I entered the field I didn't get a lot of advice on the best way to do this so I just kind of made it up as I went (I contracted to schools where I was the sole SLP). I worked at a residential facility school my first year on the job. These types of facilities get audited more often and of course we got a big audit my FIRST year (this was in 2009)! I was super nervous about it but was sure that I had documented all of my services!
When the auditors came, they selected several student's files to audit and instructed to bring all of my documentation (specifically my "evidence of provisions of services") to an audit appointment. I kind of panicked because I didn't have a form that said EVIDENCE OF PROVISIONS OF SERVICES!! ha ha ha Luckily my supervisor explained that this just meant my log of services or therapy session notes.
Here is what I had at the time:
This is an example of the log I kept, all of the names/data were made up in the image below. I kept one log for each day of therapy (I even put my lunch breaks, parent conferences, and ARD times on it! ) I also kept a calendar for each student (I checked the box on my calendar if I saw them or put a code for absences).
(I know some of you are probably chuckling at my rookie mistake, when I look back now I chuckle myself!!!)
I brought all my logs and the calendars for the selected students to my audit appointment and quickly found out that I was doing it ALL wrong. The auditor told me that she could not accept my documentation because it listed all of the students. She told me she could only view the students she selected and I would have to make copies and black out the other student's names one by one (she needed a separate log for each student selected). She told me that I should keep a log of session notes separate for each student. She suggested that I re-do my documentation and submit it to her by fax by the next morning. AHHHHH I had to re-do 8 student's logs for the past 6 months of therapy (thank goodness not longer!).
While I had an auditor's attention.......
I had many other unanswered questions about documentation that I decided to ask this particular auditor directly.
Here were her answers (let me add she was very helpful and only a little intimidating for a newbie SLP):
*Is a log sufficient to show "Evidence of Provision of Services" or would a detailed SOAP note (in paragraph form) for each session/student be better? She said that as long as all of the information is documented, a log would be fine.
*Do we need to keep record of sending progress notes home? "Yes" Although she didn't have any specific suggestions of how to do this. I make a copy of each progress note and write the day I sent it home on the top. I then file it in their working folder in my office.
*Do we need update the student's IEPs in the permanent file EVERY 6 weeks or can we submit a completed IEP at the annual ARD. She said there needs to be documentation of the progress but it doesn't necessarily have to be in the permanent file every 6 weeks. She stated as long as there is a record in their working file. She said you MUST submit a completed IEP with all of the progress data at the annual ARD.
*What information do you need specifically on therapy logs or session notes?
- Time (exact time range...11:02-11:32)
- Therapy plan (artic chipper chat, story comprehension, Grannies Candies)
- Specific goals/objectives addressed (I numbered mine so I could easily just write in the objective number we targeted)
- Progress data (percentages, session comments, or a progress code).
*Do you need to document all indirect services for students even if they don't have specific indirect services listed in their IEPs? She said that you will only be audited on services listed in their IEP. I suggest that you document ALL indirect services (anytime you train a teacher, modify a classroom with visuals, or make materials specific to the child). I ended up making a form for this that I keep on each student.
That night after my audit appointment, I gathered up all of my documentation and re-did each of the student's therapy logs. I finished up around 2 in the morning and faxed it in at 7:45am. The auditor contacted me and said she had everything she needed! She even thanked me for my hard work!
So as a result of this experience, I created my own daily logs and calendar to keep on all of my school-based clients. It follows the model the auditor said they look for and made it easy to keep track of 60+ student's progress.
I created 3 different logs:
- Direct services log
- Indirect services log
- Direct Consult log
Each log and calendar has a key for easy documentation. The keys have codes for attendance, therapy format, and progress. At the top of the log you number and write in the student's objectives. This makes it easy to just write the objective # in the column "objectives addressed." See a close up view of the keys below.
When I first heard I was going to be audited I was super nervous and a little bit frightened! Now I am SO happy I was audited in my first year because I got an idea of how I needed to keep track of my services!
I shared this story with a colleague and she said "Well Mandi that's great and all but EVERY auditor does it a different way!" I just laughed and said "Well if that day comes, I will just ask him/her what they want and compare the two!!"
My Motto: JUST DOCUMENT! If you do, you will feel confident during an audit!
Please note, I was audited by my state education agency. Each state and district has their own guidelines for auditing and documentation! This post was just to share my experience!
If you would like to use my logs too, they are available in my TPT Teachers Pay Teachers store. I have a color version and a black and white (I only use the black and white, but the color one is fun!).
Here is the Black&White Version
Here is the Color Version
Click here to visit my Store
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