2. DOCUMENTATION
Documentation is a critical vehicle for conveying essential clinical information
about each patient’s
diagnosis
treatment
outcomes
for communication between clinicians and payers
Documenting pre-therapy and lesson plan are necessary so that we select the
appropriate goal as a target and view the progress of achieving the target.
3. PRE THERAPY
The pre therapy or plan of care including an evaluation ,should document
necessity for a course of therapy through objective findings. Documentation of pre
therapy should list the conditions and complexities and where it is not obvious ,
describe the impact of the condition and complexities on the prognosis and or the
paln of treatment so that it is clear to a reviewer that the services planned are
appropriate for the individual.
Pre therapy assessment includes
informal rapport (observation)
case history
oral peripheral mechanism examination
standardised assessment tools for the specified disorder
functional assessment
speech assessment
4. The pre therapy should be documented and this documentation contain at
minimum the following information
diagnosis
long term treatment goals
type , amount duration and frequency of
therapy services
5. LESSON PLAN
Lesson plan can be an outlet of how we communicate our services to other
professional or parents.
It keeps us organised and on track as we set goals for services.
We set what short term goal can be taken , the approach , the technique to
elicit the target goal , and the reinforcement used to elicit and motivate the
client are documented in lesson plan
It validates that we provide quality care and service to the client for each
session.
Lesson plan gives out the clear idea in what manner the clinician approaching
the client to elicit the target.