The Speech Source
Mary Brezik and Kim Dillon are two pediatric speech-language pathologists with over 25 years of combined experience. As speech therapists, we are often the first professionals to assess young children once they are referred by their pediatrician. Either they are not talking well or they are not eating well. We get to know our patients, their families, and how they are developing. We have a front row seat during the first critical and formative years of development for those who receive our services. Because of this, we have developed relationships with other professionals, observed what parent questions and concerns often arise, and see a need to share the resources and information we have compiled over the years. Join us as we dig into topics that show all of the overlapping aspects of child development and intervention. We invite you to be a part of our collaborative platform as we discuss, learn and grow for the betterment of our kids!
The Speech Source
Setting Up for Success Part 4: Documentation
In this episode of the Setting Up for Success series, Mary and Kim talk about documentation! Love it or hate it, your documentation system can either drain your time or save it. Mary and Kim walk listeners through how they’ve simplified their approach to notes while still meeting all the necessary requirements—and keeping parents in the loop.
They share how their practice uses Simple Practice, a digital EMR system they love for its features and flexibility. But instead of typing up detailed SOAP notes after every session, they often use a paper-based daily note that doubles as a parent-friendly handout. It’s quick to fill out, easy for families to read, and can be uploaded to the EMR with a simple photo. Bonus? Parents get instant feedback in their child’s folder.
Mary and Kim emphasize that clarity and purpose are more important than long, wordy notes. Their paper system includes the goals for each session, progress percentages, and homework suggestions—so everyone’s on the same page. For more formal reassessments or complex cases (like medically fragile kids), they switch back to the digital templates in Simple Practice to keep collaborating teams informed and organized.
They also explain how their paper notes are helpful for teacher conferences and progress reviews—especially when you’ve got consent to share info with educators. It keeps teachers involved in therapy carryover without needing to dig through emails or portals.
Throughout the episode, Mary and Kim encourage SLPs to ask themselves:
What’s the goal of this documentation? Who needs to read it? And how can I make it useful without overcomplicating it?
If you're a therapist looking to streamline your own documentation process, Mary and Kim offer ready-to-use templates on their website and have even compiled a full Policies & Procedures List for starting a private practice.
Resources Mentioned:
🖥 Simple Practice – Try it with our discount code
📄 Documentation templates & P+P Checklist: TheSpeechSource.com
Also, if you haven't done so already, follow our podcast! You will be the first to know when new episodes release. We would also love for you to leave a review and rate our show. The Speech Source appreciates your feedback and support! Follow here!
Follow Kim and Mary on IG here! - https://www.instagram.com/thespeechsource/
For more information on speech, language, feeding and play - visit The Speech Source Website - https://www.thespeechsource.com/
Welcome to the Speech Source Podcast. My name is Mary Brzeek and I'm Kim Dillon.
Speaker 2:We are two pediatric speech-language pathologists with a combined 25 years of experience.
Speaker 1:We are your source for speech, language feeding, play and much more in between. Today we are going to be talking documentation. This is a huge source of contention for some speech therapists and professionals and a huge time suck or a time saver, depending on how you have your processes. So we thought we would talk through the ways that we have decided to do documentation for the speech source and then talk about how we basically went back to the basics to be able to really think through the purpose of our documentation and why it's important and what it's used for and how can that serve us the best that it can without having unnecessary steps that just take up a whole bunch of time. So, Kim, why don't you lead us off on our documentation and what was the big picture foundation that we based our documentation off of?
Speaker 2:Sure. So we use Simple Practice, which is digital. It's an online program and there are a ton of documentation options in there and several different templates that you can use, and some of them are not difficult, like it's very easy to do a simple soap note electronically in that system. But what we were finding is we were in the schools quite a bit and so not only were we needing to do our online documentation, but we were needing to get information home to parents that really preferred to see something come home in the child's folder versus maybe needing to log in or checking their email. That way they just they wanted that all together in their folder.
Speaker 2:And we have some templates and we have different styles depending on what you like, that we were able to, as we're working with a child, write down notes just like you would a soap note and homework and practice to do over the week and then we were able to screenshot that and upload that as an attachment easy and quickly on our phone through simple practice, and that served as the child's therapy note for that day and it still hit all of the points that were needed in a note a therapy note and we got feedback that the parents really liked that.
Speaker 2:It was simple and it was easy to read and they were able to have something tangible and know what to work on through the week, and so that has just been something that we have done consistently for most of our kiddos. Our contractors are using it. We've tweaked here and there as we see what we need, and another way that I sometimes use it is I can plan out my sessions on that same piece of paper and then, as I'm going in, fill in if I need to put data or extra notes and then know what homework is. I really like it as a planning tool also.
Speaker 1:Documentation just became so much longer and so much more elaborate on every single note, and so instead for our practice, we said, hey, okay, a digital options have not been around forever. What did people do beforehand? Physicians and therapists would use pen and paper. They would use notes, right, and so there's nothing wrong with that, there's nothing to say that we can't write on pen and paper, and so on our daily note, it is like a half sheet, a piece of paper where we have our soap note, we have the objective, we write down what we did that day, the goals are listed, which I always think is really helpful, because then every single session, the parent is able to see this is the goal and this is how we worked on it, this is the goal. And then there's a box right next to it and it says this is the accuracy. So it's always okay. We were working on S blends and they were 50% accurate. Today in imitation, so we're able to document and so have parents be so much more involved and a part of our progress. Because the thing that I didn't really like about digital daily notes is that they're really pretty blind to the family. They never see that. You go and write it later, after the patient is long gone. I think it's really helpful that we do our notes in a way that is very data-driven and shows exactly what we did for the day. But that page, we take a picture of it and then upload it as an attachment that attaches to that daily visit in our digital system and then that piece of paper then continues home with the child and so there's never any doubt that A we were there, we were physically there at the school that we went to, and then we have that copy for ourselves and for the parents. So with simple practice, you can make all of the notes viewable so that if they want to go in and just look oh gosh, we forgot the piece of paper, the dog got it, something spilled on it, no big deal they can go back into the portal and open up the note of what was sent home. That has been so helpful to have the parents involved.
Speaker 1:Kim and I talk a lot on our episodes about our favorite EMR system, simple Practice. We are a huge proponent of this system. We love all the features. It has really, really helped us grow our private practice, especially in creating our policies and procedures. So be sure to check out the show notes for our special discount code, so that you can also see all the amazing things that simple practice can do to help your business grow. Now, one of the things that we had to problem solve with this, though, is that the daily note works really well. What we had to figure out, though, was, although that's a great daily strategy, we needed an additional strategy to show progress over time, and re-evaluation or re-assessments is that you're not pulling up the full care plan and the full bulk of all of your goals and the history very quickly of where it's been. You do have to go in and see every attachment, but, kim, can you talk about how you address this and how do you handle reassessments and knowing when you should adjust goals and things like that?
Speaker 2:So I've actually done this two different ways and I will still use the online or the digital portion of simple practice.
Speaker 2:If I'm needing to kind of reassess and look at all of our goals and give progress on every single goal and maybe make a new plan, I will use one of the templates on there and go ahead and do it online and send it through email and also print off.
Speaker 2:But then we have also created a another paper template that is more detailed than the daily notes and it is a progress note where it has room for all of the current goals and where they are percentage wise for each one of those goals and then notes at the bottom, an assessment of where are we going next.
Speaker 2:Just some other observations and input, and I found that these are really helpful when it's time for a child's parent teacher conference and you can fill these out for the parents and they can take that and share that with the teacher and they have that in hand and it's easy for both of them to read or when it's I'm doing several right now, as kids are finishing up the school year for preschool and a lot of them are wanting to take a break over the summer, so it's not necessarily time for their reevaluation, but we're going to kind of look at where we are, all of our progress and data, and I'm able to put everything on that piece of paper and, just like I would a therapy note, I will upload that if I end up doing it paper pencil, take a picture and upload it as an attachment to their file.
Speaker 1:In simple practice, what about you, mary? Yeah, I do something similar. I go back and forth as well. It depends on the patient. Sometimes I use the simple practice forms. I've used Word before and I've also used the template.
Speaker 1:Like you said, it's dependent on okay, is this a parent-teacher conference kind of progress summary, or is this a reassessment? It's been six months kind of summary. The other thing that I think that paper does that is really helpful is it lets you be so much more concise. We do not need to be wordy and verbose and have full paragraphs written for notes. No one cares. No one's going to read that. We don't care. The only thing that we care about is what was the goal and how did we make progress and where are they currently, where are they going? And so I think that when you are manually having to write out all of those bullet points, it does let you really be a lot more concise and a lot more just goal-driven, really to think about progress as the end goal, not anything else like what game you played or how you got there specifically.
Speaker 2:Yeah, and I think it's like with everything else just making sure that you know the families and the parents and what they prefer and what they want. I would definitely say the majority of my parents want something easy and simple to read. They just want to know how they did and what they want to do. Almost like I probably have parents that would prefer a text message at the end of the session, just like a quick couple sentences. This kind of serves that purpose. As soon as the kid gets home from school and picked up, they can see you right there in their folder, what we did, and it's almost like I just sent him a text message.
Speaker 2:But then of course, there are times when more is needed and that's why I would never want to get away from an EMR system like simple practice, especially when you're collaborating with other therapists or professionals and they need more details. You still have that option to really get those details in there and write up a bigger picture of what's going on. Or maybe there's a time when the family is, okay, I need more and you're like, okay, I'm going to do a full report here or a full progress report. You have that option too, so just knowing when to use which one, and that's really how I decide what I'm going to do at that time.
Speaker 1:I would say one example of when I prefer a digital EMR system is for my really medically complex kids that do have multiple professionals and we're trying to get to the bottom of what medical issues are going on. I shared two patients with one of our contractors for feeding therapy and they also have some speech language things. But one of the things that we're discussing right now is the aspiration there's modified barium swallow studies. They were discussing scope with ENT and pulmonology and seeing how all these things are related.
Speaker 1:That is a situation where 100% that's not a piece of paper handwritten kind of situation. Basically I still use my paper as the daily notes of what we're doing, but I do use the digital version for the progress summaries that are really helpful and then basically bullet point that and type it, because that's quite a bit more and when you have other professionals who are collaborating on the team, that is quite a bit easier to read typed. But I think that the biggest thing is about all of this documentation is that you have to ask yourself questions of what is best for the patient, what is the purpose of documenting, what is the best mode of delivery to get parents to feel like they are a part of the progress, even if they're not present, especially if you're at a school. And how are you going to do that in a HIPAA compliant way?
Speaker 2:And that was one last point I wanted to make with the paper is that if you do have that release with a preschool teacher like we talked about in one of our episodes our HIPAA and release forms that's a really easy way for, if you do have consent for the teacher to have information on how that child's doing in speech therapy, they are able to see what they could help with in the classroom, as they're putting that into the folder, and I think that's just another way to share information with the teacher and have them helping as part of the child's team, as long as you have that consent.
Speaker 1:Yeah, it's so much easier to feel like when I walk into a class to return a child to their classroom. I can just point out those three bullet points of here's our goals. This is what we're working on, Instead of doing a play by play of we did this at the beginning and then we don't need a narrative we just need. This is what we worked on. This is what really helped them today.
Speaker 2:So that's how we do it, and we've had a lot of really great feedback, not only from parents but also the contractors that are working with us, and we've really liked it, and so those are actually on our website, those templates I think there's five different ones that are available. If you are interested, you can check those out. As we record this mini series on policies and procedures, Mary and I have put together a list of everything that we feel is important in starting a private practice all of the policies, the procedures, the paperwork that we use and that is available in our podcast notes. Just click on the link and you can download this list for yourself. Hopefully it's helpful in starting your own practice. Thanks for listening. Make sure you subscribe to our podcast and check out our website, thespeechsourcecom.
Speaker 1:Also check us out on Instagram for more ideas on speech, language, feeding and play.
