After much demand, I put together a 120-page comprehensive documentation guide that has everything you need to get started documenting if you are new to working with adults. Many of my CFs and mentees have stated what helped them the most in learning how to document for adult medical patients was reading and looking at my sample reports for wording ideas. If documentation gives you a headache, this resource is for you!
This PDF e-book contains 20 full reports totaling 90 pages that I've written for actual patients covering all major areas including AAC/ ordering speech generating devices, swallowing assessments (including FEES), voice evaluations, speech-language assessments, aphasia evaluations, and cognitive-linguistic assessments. It also includes a goal bank grouped by category with a color coding system for identifying key components of each goal. Sample SOAP notes also included.
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