Speech Therapy Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Speech Language Pathologist Note

Patient Identification:
[Patient name, age, gender, relevant medical history, reason for referral]

History of Present Illness:
[Description of current communication, speech, language, voice, fluency, or swallowing concerns]
[Onset, duration, and progression of symptoms]
[Associated factors or relevant events]

Past Medical History:
(hyphenated list)
- [Relevant medical diagnoses]
- [Surgical history]
- [Developmental history]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]

Allergies:
(hyphenated list)
- [Drug/food/environmental allergies]

Family History:
(hyphenated list)
- [Relevant family medical or developmental history]

Social History:
(hyphenated list)
- [Living situation]
- [Education/work status]
- [Support systems]
- [Communication needs in daily life]

Assessment:
(hyphenated list)
- [Speech assessment findings] (e.g., articulation, phonology, fluency, voice)
- [Language assessment findings] (e.g., receptive, expressive, pragmatic)
- [Cognitive-communication assessment findings]
- [Swallowing assessment findings]
- [Other relevant observations]

Impressions:
[Summary of clinical impressions, diagnosis, and impact on function]

Plan:
(hyphenated list)
- [Therapy goals]
- [Intervention strategies]
- [Home program recommendations]
- [Education/counseling provided]
- [Referrals to other professionals]
- [Follow up plan]