WEB-BASED CLINICAL PROGRESS TRACKING SYSTEM | DOCUMENTATION & CASELOAD MANAGEMENT
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TreatWrite
Member Spotlight
Writing Functional
Progress Statements
 
 

SALLY McKEE is an outstanding TreatWrite user who has made significant contributions to the field of speech pathology for over 30 years. She has worked in a school setting, university setting, doctor’s office, and spent twenty-two years as the Director of Speech Pathology Services for Sally McKee & Associates.

The main focal points of Sally’s professional contributions are in the areas of voice care and stuttering remediation. Her versatility inspires all her clients. She helps singers speak, stroke victims sing, and Texans lose their accents while actors learn to use one. She teaches children to talk and parents to listen so people of all ages can enjoy their communications with each other.

In addition to her outstanding clinical expertise, Sally uses her talents to inspire other professionals. She has presented over sixty workshops to various local, state, national and international groups on a variety of speech pathology related topics. Sally earned the “Outstanding Service Award” from the Texas Speech-Language-Hearing Association and served as the President of the University of Houston Alumni Association.

Sally listed her favorite TreatWrite features as the time TreatWrite saves her and the Daily Appointments Calendar. Congratulations Sally, you shine in the TreatWrite Spotlight!

Professionals Section Coming
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TreatWrite members will soon be able to use their user id and password to log into the professionals section of this website. The professionals portion of the website will offer TreatWrite subscribers the opportunity to view additional tutorials focused on documentation success, learn tips for using TreatWrite to facilitate successful appeals, keep up with current industry reimbursement regulations and trends, and participate in member seminars on marketing, advocacy and business management. Stay tuned for exciting things to come!

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TheraTech wants to recognize a professional TreatWrite user each month. Help us select our next award winner by nominating a very special TreatWrite user. Send your nominations to suggest@treatwrite.com

By: Gretchen Bebb
Author: TreatWrite Clinical Progress Tracking System

Progress statements on the Progress Report should create a clear understanding about the cause and effect relationship between treatment activities and functional gains. Understanding how treatment activities lead to functional progress gives readers, including insurance claims reviewers, physicians, clients and family members, a substantive image reflecting the purpose and outcome of therapy. The most effective progress statements use consistent clinical measures. The most accurate tools for determining and reporting clinical progress include test retest data, and objective clinical measurements.

The logic behind successful progress reporting is to 1) use comparative statements to substantiate objective progress toward established goals, 2) describe the functional impact of service period gains, 3) develop “next step” or “upcoming” statements, and 4) tie upcoming skill focus to short term goals.

The following is a successful structure for reporting progress. The client improved from _____ to ____(on a specific objective). This resulted in ______ (functional improvements). Upcoming treatment will focus on _______. Support this statement with appropriate short term goals.

Clinical example: (Comparative statement) Monthly test/retest results from the immediate memory subtest of the Ross Information Processing Assessment showed that Margaret improved her score from the 70% to the 80% level. (Functional progress statement) Margaret is now able to retain two-element facts long enough to write key ideas for future reference. (Upcoming goal statement) Upcoming treatment will focus on increasing Margaret’s ability to describe daily events while diminishing her reliance on visual memory support.

The subsequent short term goal reads: “To give Margaret the ability to recall three related daily events she will: 1) retain two related facts for 10 minutes without written support with 90% success. 2) recall three events from a single story paragraph with 75% success. 3) Etc.”

It is important to recognize statements that do not describe progress or support insurance coverage. Inadequate progress statements leave the reader with questions about the progression of therapeutic events and/or the functional result of treatment. Examples: 1) Susie showed consistent responses (no statistical support). 2) The client is able to inject air 80% of the time (no data comparison). 3) Auditory comprehension improved from the moderate to mild level (insufficient objective information). In addition to the limitations of each of the previous examples, none of these statements show functional relevance.

Correctly formulated cause and effect progress statements leave readers with a clear understanding about the purpose and impact of treatment. The TreatWrite Manual located in the Help Menu of the TreatWrite toolbar gives additional examples of successfully architected progress statements.

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