Try your hand at documenting a skilled dysarthria session and compare yours to the three I wrote. I share a dysarthria therapy session that follows the principles of motor learning, ASHA’s guidelines on skilled documentation, and three sample visit notes. I’d love to hear your feedback and how you would document the session.
Free DIRECT download: Skilled visit note checklist (clinician cheat sheet). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Outline:
- Meet our patient, Mr. Smith.
- Mr. Smith’s motor speech goal.
- Our dysarthria therapy session.
- Write our visit note.
- The skill we demonstrated in this session.
- 7 components of skilled documentation.
- My skilled visit note with all 7 elements.
- The skills my visit note reflects.
- Does the visit note have to be this long?
- A shorter skilled visit note.
- An even shorter skilled visit note.
- How would you document this session?
- Learn more.
- Related Eat, Speak, & Think posts.
Meet our patient, Mr. Smith
Our patient, Mr. Smith, is 58 years old and has chronic mixed flaccid-spastic dysarthria after suffering from two strokes, the most recent being 10 months ago.
The main characteristics of his dysarthria are:
- Imprecise consonants.
- Distorted vowels.
- Hypernasality.
- Monoloudness and monopitch.
- Excess and equal stress.
- Slow speaking rate.
He is 25% intelligible when saying single words to an unfamiliar listener in a known context. Family and friends can often guess what he is trying to say, but as you can imagine, communication is quite challenging.
Mr. Smith’s motor speech goal
While we’re working on AAC to support communication, his primary goal is to improve his speech intelligibility. We’ve worked together with his family to identify 10 words that would be helpful for him to be able to say clearly enough to be understood without AAC support.
His primary goal:
Mr. Smith will produce at least 8 words from a set of 10 personally-meaningful words clearly enough to be understood when the listener does not know the intended target, independently using recommended strategies to improve daily communication and reduce frustration by 5/29/2021.
Our dysarthria therapy session
Here’s a summary of the speech therapy session we had today. For this session, everyone was wearing an FDA-approved clear face mask.
First, we collected baseline data
First, we decided to collect baseline data for the session. We gave him a stack of 20 index cards after we shuffled them. Each card has a single word: either one of his 10 words or one of 10 other words that are similar. He worked his way through the stack, reading each word aloud without showing us the card.
Because he finds it motivating to know his score , we were transparent about his performance. We repeated what we heard, and he showed us the card. If we correctly understood him, the card went in one stack. If we didn’t, the card went in another stack.
At the end of the baseline probe, we found that we understood 4/10 words from his personal word list. He was determined to improve his score when you repeated this task at the end of the session.
Next, we conducted speech therapy
Because he was having such trouble saying the words, we decided to have him repeat each word after us. When he had trouble repeating a word, we provided massed practice. We broke the word down and practiced sounds and syllables, then blended the word back together.
If he had trouble making a sound following our model, we asked him to say an easier word containing that sound, perhaps in a different position in the word. We told him to pay attention to how it felt and sounded to make that sound, the repeat it. Sometimes, we pulled out a mirror and had him watch himself to improve the placement of his articulators.
Once he was able to say the word, we decided to introduce some unpredictability into the practice. We asked him to repeat various two-word phrases for each target word. If he had difficulty, we used the same types of strategies to maximize his performance.
Occasionally, we recorded him and had him listen. We asked him to point on a number line to judge his own performance, where 1 means someone would have a lot of trouble understanding him and 10 means someone could easily understand him. Sometimes we shared our own judgment.
We spent the bulk of the session working our way through the 10 words in this manner, moving from one word to the next when we judged that Mr. Smith had practiced as much as he could without losing motivation. In order to keep motivation high, we tried to end the practice of each word on a successful note.
Then we repeated the probe
Once we finished working through the words in this manner, we repeated the probe task from the start of the session. This time, we were able to understand 7/10 words. Mr. Smith was understandably pleased and encouraged.
Finally, we ended with teaching and training
As the session wound down, we assessed his understanding of the strategies that helped him to say the words more clearly. He gestured to show that he made bigger movements of his mouth and demonstrated to show that he spoke a little more loudly. We reinforced this and reminded him to practice his words every day for his home exercise program.
We asked him to tell us what his home exercise program was. He gestured to support his response, conveying that he first watches the videos we made for each word, showing a close-up of our mouth as we said each word. After repeating the words until he felt he was saying them as best he could, he sits down with his wife to go through the cards. His wife arrived home at that point, and we asked them to demonstrate.
His wife picked up the stack of cards and asked her husband to repeat each word after her. We encouragingly assured her that this was a fine exercise to do. Then we re-introduced the exercise we really wanted them to do. Namely, that Mr. Smith holds the cards and reads aloud a word at a time while his wife repeats what she hears. We modeled the activity for them, then asked them to demonstrate again. We provided positive reinforcement and invited Mrs. Smith to join in the next session.
Write our visit note
To gain the most from this exercise, take a minute and write the visit note for this session.
The skill we demonstrated in this session
ASHA has a helpful page sharing examples of skilled activities and unskilled activities. Considering this list, here is what I think is skilled about the session above.
- We followed various principles of motor learning, adjusting the task complexity, cueing, and feedback style as appropriate to maximize performance and learning:
- Large number of trials, providing lots of practice.
- Preference for distributed practice.
- Switched to massed practice when he was struggling, then switched back to distributed practice once he was showing success.
- Provided variable practice by placing each word in a variety of 2-word phrases.
- The words were practiced in a random order.
- Preference for external focus of attention. You encouraged him to attend to how his speech sounded.
- Switched to internal focus, encouraging to pay attention to how his mouth was moving when he was struggling.
- Preference for practicing complex (whole) movements by producing whole words.
- Switched to practicing simple (part) movements when he was struggling.
- Provided feedback about the results of the movement (how intelligible the word or phrase was).
- Switched to feedback about accuracy of his movements when he was struggling.
- Provided feedback with low frequency (not after every trial).
- We adjusted our therapy activities to balance between pushing Mr. Smith to perform at a level where he was not 100% successful while still maintaining his motivation.
- We engaged Mr. Smith in practice of the desired skill while providing reinforcement to establish and strengthen emerging abilities.
- We provided ongoing assessment of his performance in order to adjust the activities during the session, as well as to plan future sessions.
- We engaged Mr. Smith in dialogue to assess his understanding of the speech intelligibility strategies and exercises.
- We trained and provided feedback to Mr. and Mrs. Smith regarding how to perform the home exercise program.
7 components of skilled documentation
The next step is capturing our skilled service in your documentation.
ASHA provides a list of seven types of information that can be included in a skilled visit note. We don’t know how many elements have to be included to be considered a skilled note by the insurance reviewer. But it’s clear from their examples that simply reporting objective data and level of cueing provided is not sufficient.
- Use terminology that reflects your technical knowledge.
- Share your rationale for the service you provided, including the type and complexity of the service.
- Document objective data that demonstrates progress towards the goal.
- Report the feedback you provided to your patient or caregiver about their performance.
- Explain your decisions to modify the therapy activity or plan of care.
- Report how you trained or educated your patient or caregiver.
- Document your patient or caregiver’s response to the education or training.
My skilled visit note with all 7 elements
One of my challenges is trying to document the skilled service I provide without writing a book. In writing this post, I’m trying to improve my own documentation skills.
Here is his goal again for reference:
Mr. Smith will produce at least 8 words from a set of 10 personally-meaningful words clearly enough to be understood when the listener does not know the intended target, independently using recommended strategies to improve daily communication and reduce frustration by 5/29/2021.
Consulting ASHA’s page with examples of skilled and unskilled documentation, here is my first stab at a skilled note:
Prior to any instruction and without cueing, patient produced his personalized word list with 40% intelligibility when produced in random order with foils. To improve his speech intelligibility, SLP followed the principles of motor learning by providing opportunity for large number of trials with preference for distributed and variable practice focusing on complex movements. In response to poor performance, SLP modified the exercise by providing massed practice and focus on simple movements until performance improved. SLP assessed and reinforced patient’s understanding of how speech intelligibility strategies relate to the exercise and to his goal. SLP assessed the patient and spouse’s understanding of the home exercise program, reeducated them, modeled the activity, and asked them to demonstrate, which they were able to do. At the end of the session, patient produced his personalized word list with 70% intelligibility when produced in random order with foils, without cueing.
The skills my visit note reflects
Here is what I think my visit note accomplished:
- Used terminology that reflects my technical knowledge.
- Shared the rationale for the service I provided.
- Documented objective data that demonstrates progress towards the goal.
- Reported the feedback I provided to my patient about his performance.
- Explained my decision for modifying the activity.
- Reported how I trained and educated our patient on the home exercise program.
- Documented that they were able to demonstrate the exercise appropriately.
Does the visit note have to be this long?
The short answer is “no.” Thank goodness! ASHA’s examples of skilled documentation are three to five sentences long, and each note does not incorporate all seven elements.
A shorter skilled visit note
Here is my attempt at writing a shorter skilled visit note, based on ASHA’s example for motor speech therapy:
Patient continues to have largely unintelligible speech production, with significant difficulty in making his needs known. When reading his list of 10 personalized words plus 10 foils in random order, he was 40% intelligible at the start of the session and 70% intelligible at the end of the session. SLP provided therapy according to principles of motor learning by providing opportunity for large number of trials with preference for distributed and variable practice focusing on complex movements, but adjusting the therapy as needed according to his performance. Patient and wife were initially unable to demonstrate the home exercise program, but were able to do so after training.
An even shorter skilled visit note
Patient continues to have unintelligible speech production with limited ability to convey his thoughts. When reading his list of 10 personalized words plus 10 foils, he improved from 40% intelligible at the start of the session to 70% by the end. Patient benefited from distributed and variable practice focusing on complex movements, adjusted as indicated by his performance. Patient and wife were able to demonstrate home exercise program following training.
How would you document this visit?
I would love to see how other SLPs would document this visit, and I bet other SLPs would like to see other examples, too. Please leave a comment below. But feel free to contact me privately, if you don’t feel comfortable sharing below.
Learn more
- “Documentation of Skilled Versus Unskilled Care for Medicare Beneficiaries.” American Speech-Language-Hearing Association, https://www.asha.org/Practice/reimbursement/medicare/Documentation-of-Skilled-Versus-Unskilled-Care-for-Medicare-Beneficiaries/.
- “Examples of Documentation of Skilled and Unskilled Care for Medicare Beneficiaries.” American Speech-Language-Hearing Association, www.asha.org/practice/reimbursement/medicare/examples-of-documentation-of-skilled-and-unskilled-care-for-medicare-beneficiaries/.
- Maas, E., Robin, D.A., Austermann Hula, S.N., Freedman, S.E., Wulf, G., Ballard, K.J., & Schmidt, R.A. (2008). Principles of Motor Learning in Treatment of Motor Speech Disorders. American Journal of Speech-Language Pathology, 17, 277-298. [PubMed]
Related Eat, Speak, & Think posts
- Articulation therapy for dysarthria: Part 1.
- Motor learning for articulation: Focus and feedback.
- Tips for dynamic speech assessment.
Free DIRECT download: Skilled visit note checklist (clinician cheat sheet). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Featured image made on canva.com.
Lisa earned her M.A. in Speech-Language Pathology from the University of Maryland, College Park and her M.A. in Linguistics from the University of California, San Diego.
She participated in research studies with the National Institute on Deafness and other Communication Disorders (NIDCD) and the University of Maryland in the areas of aphasia, Parkinson’s Disease, epilepsy, and fluency disorders.
Lisa has been working as a medical speech-language pathologist since 2008. She has a strong passion for evidence-based assessment and therapy, having earned five ASHA Awards for Professional Participation in Continuing Education.
She launched EatSpeakThink.com in June 2018 to help other clinicians be more successful working in home health, as well as to provide strategies and resources to people living with problems eating, speaking, or thinking.
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