Speech and Language Therapist Template

SLT - Telephone Clinical Note

A professional Speech and Language Therapist template for healthcare professionals.

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Specialty

Speech and Language Therapist

Used

5 times

Type

Note

Last edited

7/15/2026

Created by

Jo Mitchell

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About this template

Streamline your clinical record-keeping with our SLT Telephone Clinical Note template. Perfect for Speech and Language Therapists, this template helps you meticulously document phone consultations, ensuring all critical details from initial calls to follow-up advice are captured. Easily record the aim of the session, reasons for the call, a summary of discussions, and any advice or instructions provided. This template also features dedicated sections for your clinical impressions and diagnoses, making it simple to track patient progress and plan future care. Ideal for busy clinicians, Heidi will intelligently populate this note from your call transcripts, allowing you to focus more on patient care and less on administration.

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Specialty: Speech and Language Therapist Aim -To assess the patient's current communication abilities following a recent stroke and establish a preliminary treatment plan. Consent was obtained for the session and for the use of Heidi Ai Health Scribe. Family present: Mother (Sarah Smith), Husband (John Smith) -Patient's daughter, Maria, called regarding her 72-year-old mother, Mrs. Eleanor Vance, who recently had a stroke. Maria reported that her mother is having significant difficulty speaking and understanding others, which is causing her distress and isolation. She is also having difficulty swallowing thinner liquids. -Discussion focused on the specific communication challenges Mrs. Vance is experiencing (e.g., word finding difficulties, slurred speech, trouble following complex instructions) and her reported dysphagia symptoms (e.g., coughing during drinking). Clarification was sought regarding the timeline of the stroke and any prior speech or swallowing difficulties. Information was also gathered about Mrs. Vance's current living situation and support network. The potential impact of these difficulties on her quality of life was explored. -Advised Maria to keep a log of specific instances where Mrs. Vance struggles with communication or swallowing. Provided preliminary strategies for improving communication, such as speaking slowly, using short sentences, and visual cues. Recommended thickening agents for liquids and advised observation for signs of aspiration. Scheduled an in-person comprehensive assessment for Mrs. Vance next week. Impression - Diagnosis: Aphasia (likely expressive and receptive components) secondary to cerebrovascular accident (CVA); suspected Oropharyngeal Dysphagia. - Clinical impressions: Mrs. Vance presents with significant communication impairment impacting her ability to express needs and understand information, leading to frustration and social withdrawal. Her reported swallowing difficulties suggest a risk of aspiration, necessitating immediate dietary modifications and further assessment. Her family is highly supportive and motivated to participate in her rehabilitation. P/ -Follow-up actions: Comprehensive in-person Speech and Language Therapy assessment scheduled for 8 November 2024 at 10:00 AM at the clinic. Referral to Dietetics for swallowing management planning. Family to continue logging communication difficulties and use provided strategies. Will provide a home exercise programme following the assessment.