Harmony Healthcare Blog

Top 5 Documentation Tips for Speech Cognition (Part 1 of 2)

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Thu, Jun 09, 2016

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Edited by Kris Mastrangelo


Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

Speech_Therapy.jpgWhen treating a patient with cognitive disorders, the provider is required to demonstrate to the Medicare Contractor that the skills, knowledge and judgment of the licensed professional are necessary due to the patient’s new onset of symptoms or there is potential to effect change in the patient’s condition.  Today’s blog is a two part series. Here are suggestions to better support the documentation in the medical record.

1.  Define patient gains at a microscopic level.

Many times, therapists feel and understand that the therapy involvement is valuable to the patient.  However, they cannot detail the significance in their notes.  Therapists need to know that breaking down the benefits into small, incremental levels is a potent method to depict patient benefits.  The therapists ability to document at this way takes a keen eye and years of treatment time with cognitively impaired patients.   The following statements can help to effectively depict the benefits and impact of therapeutic interventions: 

  • With verbal and visual cueing, the patient demonstrated adequate attention to comprehend tasks related to basic, medical and social needs.
  • When rate of verbal messages was slowed, patient could follow simple directions.
  • When utilizing visual prompts, the patient could participate in tasks designed to improve verbal language related to medical needs communication. 

Example progress note for a patient with language/cognitive deficit: 

“Patient improved with word naming skills. Trained in use of auditory and visual stimuli to facilitate verbal expression related to medical needs. Additional training to improve attention to therapeutic task provided tactile cueing.”

“Intentional training procedures helped patient focus on auditory/visual stimuli and enabled patient recall names of body parts and medications necessary for patient’s care.”

2.  Set goals that are measurable and patient related. 

When treating and documenting on a patient with cognitive impairments, setting goals focused on cognition need to be measurable and patient related.  Harmony Healthcare International (HHI) offers examples for setting measurable cognitive based goals.  Descriptors of the cognitive impairment are essential to depict the rationale for skilled services.  Some examples include: 

Attention:  “Patient will attend to ADL tasks for a 30 minute session with rare cues to regain attention.”

Sequencing:  “Patient will properly sequence bathing and dressing tasks 3 out of 5 trials with supervision only, using visual aide provided by ST.” 

Memory:  “Patient will demonstrate recall of a.m. self care schedule when prompted by ST, 60 minutes following completion of session.”

3.  Use Standardized Evaluations

Standardized Evaluations and Tools are essential for laying the foundation for patient performance and affords creditability to the documentation secondary to the research and inter-rater reliability aspects of the tools.   Speech Therapy notes should refer to the administration of any standardized evaluations used with the patient in addition to the initial evaluation performed.  When standardized evaluations have been completed, a copy of the score sheet should be present in the patient’s record along with the rehabilitation progress notes.

4.  Refine your Terminology 

Words are vessels.  Choose your words carefully! You can say the same thing but with a very different impact on the reader.  I am giving you an example of a simple email correspondence that shows how words change the perceived message. (An employee has a busted computer and needs help). 

For example, a message from employee to IT (Information Technology Department): 

a.  “Sorry to bother you at this early hour. My computer is having trouble, when do you think IT could take a look because I have a big project due for a customer? Thank you so much for your attention to this matter.”

b.  “My computer crashed!! I need it fixed now. Send a tech asap.” 

The following table offers choices and guidance on how to describe the patient’s status: 

Refinement of Terminology 



Generalized weakness/deconditioned

Functional strength deficit


Activity tolerance

Poor gait

Gait disturbance


Specify amount


Specify amount

Occasionally, periodically, sometimes

Specify frequency






Attention span




Beginning to respond








Progress may still occur without an obvious improvement from one level of assistance to anotherIn these cases, be sure to describe the positive benefits and rationale of therapy.  Terminology helpful in these situations: 

  • Change in behaviors toward set goal areas.
  • Performance of a new functional task.
  • Greater consistency in task performance.
  • Increased tolerance for participation in therapy.


“Although the patient continues to require moderate assist with transfers, she demonstrates increased consistency in her ability to recall hip precautions during mobility tasks.”

“Although the patient reports pain remains at 5 of 10, pain management techniques including positioning and visualization reduced the number of refusals by 75% during this treatment period.” 

5.  Describe obstacles to performance. 

If the patient does not demonstrate significant progress over the past week, explain the lack of progress by documenting the factors that are limiting significant progress.  

This data is essential when progress may be minimal or slower than anticipated.  Include any modifications to the Plan of Care or Goals during this time. 


“The patient is motivated to participate; however, gains are limited by frequent episodes of lightheadedness and low blood pressures during standing activities. Nursing is aware of these episodes and continues to address medication changes.  Patient is at risk of loss of functional mobility skills with medical complications in the absence of skilled therapy.  Please see modified goals and treatment plan to include table top activities and lower extremity exercises in sitting until blood pressure stabilized.”

“Patient has demonstrated limited progress this week due to nausea and vomiting that resulted in an inability to tolerate physical activity for greater than 10 minutes.  Expect resolution of symptoms with recent medication changes.  Treatment plan goals have been modified to include energy conservation and work simplification strategies. ” 

Stayed tuned for Part 2 of this blog series, which will be posted next Tuesday.  If you have questions about Speech Cognition Documentation, please contact Harmony Healthcare International by clicking here or calling our office at 1.800.530.4413. 

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Tags: Speech Therapy, Compliance, Speech Cognition

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