Use this checklist to review documentation before signing. All elements must be present for payer compliance and medical necessity support.
Evaluation Report
- Patient demographics, DOB, diagnosis codes (ICD-10)
- Referral source and reason for referral
- Relevant medical/social history
- Prior level of function (PLOF)
- Standardized and non-standardized assessment tools used
- Objective findings with scores/percentiles
- Clinical impressions and diagnosis
- Functional impact statement
- Skilled care justification
- Recommended frequency, duration, and goals
- Patient/caregiver education provided
- Therapist signature, credentials, date
Treatment Note (SOAP / DAP)
- Date of service, session duration, CPT codes
- Patient attendance and participation level
- Objective data for each goal addressed (% accuracy, trials, cues)
- Skilled interventions described (not just activities)
- Patient response to treatment
- Progress toward goals (improving / maintaining / declining)
- Plan for next session
- Therapist signature, credentials, date
Progress Note / Recertification
- Summary of progress since last certification period
- Current status on each goal (with objective data)
- Updated functional impact statement
- Continued skilled care justification
- Updated or revised goals
- Estimated duration to achieve goals
- Discharge planning considerations
- Physician/provider signature (if required by payer)
Discharge Summary
- Reason for discharge
- Summary of goals achieved vs. not achieved
- Discharge functional status vs. PLOF
- Home program provided
- Referrals or follow-up recommendations
- Patient/caregiver education at discharge
Tip: Medical necessity must be documented in every note. Ask: "Would a skilled SLP be required to perform this service?" If yes, document why.