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Speech and Language Therapist Template

Review Speech Pathology Assessment

A professional Speech and Language Therapist template for healthcare professionals.
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About this template

Enhance your clinical documentation with our 'Review Speech Pathology Assessment' template, a crucial tool for Speech and Language Therapists. This comprehensive template streamlines the process of tracking patient progress, updating communication and swallowing statuses, and outlining future therapy plans. Ideal for both public and private practice settings, it ensures all vital aspects of a patient's journey, from goal attainment to caregiver feedback, are meticulously recorded. Heidi, our AI medical scribe, uses this template to transform your spoken words into structured, detailed notes, ensuring accuracy and saving you valuable time. Optimise your patient care and reporting with this essential speech therapy documentation example.

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Review Speech Pathology Assessment Purpose of Review: Reassessment of communication skills following a 6-month block of intervention focusing on expressive language development in a 5-year-old child diagnosed with Developmental Language Disorder. Progress Toward Goals: Significant progress observed in expanding vocabulary and sentence length. Family reports a noticeable improvement in '[Patient Name]'s ability to form 3-4 word sentences spontaneously at home. School reports indicate increased participation in group activities and improved ability to convey needs to teachers and peers. "[Patient Name]" successfully identified 8/10 common objects and actions during structured play. Current Communication Status: Receptive language skills are within age-appropriate expectations for single-step commands. Expressive language has shown marked improvement, with an increase in mean length of utterance (MLU) from 2.5 to 3.8 morphemes. Speech clarity has improved, with a reduction in phonological errors, specifically fronting and stopping. "[Patient Name]" is now consistently using gestures to supplement verbal communication when explaining complex ideas. Interaction with peers has become more frequent and sustained, with less reliance on adult prompting. Swallowing Status (if applicable): Not applicable. This review focuses solely on communication development. Therapy Completed to Date: Eighteen sessions of individual language stimulation therapy delivered weekly at the clinic, focusing on narrative skills, vocabulary expansion, and sentence formulation. Caregiver education was provided weekly on strategies for promoting language development in the home environment, including recasting and parallel talk. Compliance with home activities, such as reading daily and engaging in descriptive play, has been excellent, as reported by the mother. Updated Goals: New goals established collaboratively with the parents include: "[Patient Name]" will independently initiate a conversation with a peer at crèche on 3 out of 5 observed occasions, and "[Patient Name]" will produce grammatically correct sentences of 4-5 words to describe a past event, using appropriate verb tenses, in 80% of opportunities. Recommendations / Next Steps: Continuation of weekly individual therapy sessions for another 12-week block to target narrative skills and social communication. Referral to audiology for a routine hearing check to rule out any underlying auditory issues. Recommendations provided to the crèche teacher for incorporating visual schedules and choice boards to support communication during transitions and group activities. "This set of notes has been produced with the assistance of an AI-scribing service. I confirm that verbal consent has been obtained from the patient. I have reviewed the content of notes and confirm that these are a full and accurate record of my clinical assessment."
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Specialty

Speech and Language Therapist

Used

10 times

Type

Note

Last edited

22/01/2026

Created by

Heidi Team

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