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Speech Language Pathologist Documentation Software

 

Secure Documentation Management

Documentation is an important part of every SLP’s job. It’s not only a representation of your clinical expertise and skilled knowledge, but it’s critical for insurance reimbursement. Documentation is used to track progress, demonstrate medical necessity for intervention, and advocate for your client’s communication needs.

As an SLP, you need a secure document management system to store your important documents. Your consent forms, intake forms, and SOAP notes contain so much PHI that you and your clients need to feel secure that your document management system is protected. SimplePractice is totally HIPAA-compliant and is the only EHR to be HiTRUST-certified, so you can rest easy knowing that all your client data is completely secure.

Documentation Made Simple

Your documentation management solution should make writing notes easier and save you time. SimplePractice allows you the flexibility to create and individualize note templates across your diverse caseload. You can update your evaluations, daily notes, and SOAP notes to include dropdown menus, checkboxes, and preloaded phases and answers, so you can quickly fill them out after each session.

Reduce the amount of time you spend on building templates by making use of the SimplePractice template library, which offers a variety of preloaded templates for both pediatric and adult treatment. Any note template you choose, from voice evaluation to articulation therapy progress note, can easily be customized, meaning you no longer have to create each note from scratch. Whether you specialize in feeding or fluency, your evaluation and daily note templates can be easily customized to meet your practice’s clinical needs.

Once your ideal note template is created, you can easily select the template, reference the client’s plan of care goals, and begin entering your daily note during the session. SimplePractice also offers the ability to load the previous note, saving you time for future session notes.

Once a note is completed, it can be electronically signed with just a click. SimplePractice’s clinical notes also autopopulate the client’s CPT codes, diagnoses, and appointment duration times, so that you can ensure your documentation is compliant for insurance payer requirements.

Many insurance payers require a progress note to be sent to them after a certain amount of treatment sessions to determine if additional therapy is medically necessary. The progress note typically requires a report of the client’s progress towards their plan of care, or an updated diagnosis and treatment plan. SimplePractice’s treatment plan feature allows you to easily select a diagnosis with the ICD-10 codes prepopulated, and enter goals for the plan of care. You can also set reminders to alert you when a client’s plan of care needs to be updated, so that you can get your progress notes sent in on time.

Client Forms, Streamlined

SimplePractice gives you the flexibility to create and customize your own intake questionnaires and consent forms. Whether you treat adult clients with cognitive difficulties or pediatric clients who need their parents to fill out questionnaires, online documentation management in SimplePractice streamlines the entire process.

The Client Portal gives your clients a centralized and secure location to sign their consent forms, so you can ensure your clients’ privacy. This portal makes it easy for your clients or their caregivers to sign consent forms, fill out intake paperwork, and upload reports to facilitate their care. Once these forms are completed by your client, the consent and intake forms are seamlessly attached to your client’s record within SimplePractice. You even have the option to create consent and intake forms in various languages to support your culturally and linguistically diverse client base.

The Client Portal also gives you the ability to manage any worksheets, parent education handouts, and carryover activities for your practice. Easily access your handouts on vocal hygiene tips or language development to share them with parents to download in the Client Portal. Plus, there’s no limit on the amount of files or intake forms you create and share.

Supervision Made Simple

Clinical fellows, SLPAs, or graduate students who are prelicensed and under supervision can sign and share SOAP notes and other documents directly with their supervisor. Then, supervisors can review the notes, make edits or suggestions, and sign and lock each note—all from the same place. Plus, the Appointment Status Report can help your practice track the status of your daily notes for your clinicians.

 

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