Reviewed by Lois Jean Brady, M.A., SLP
To draft speech therapy session notes in EASI, choose your student, add a session, and add your notes your way: record, add files, type, or use quick marks. EASI drafts a full session note as a SOAP note, a narrative, or a quick note. You read the draft, change anything, and it is saved to your student's record.
What should a daily therapy note include?
For Medicare outpatient therapy, a treatment note is required for every treatment day and every therapy service. It must include the date of treatment, each specific intervention provided and billed, the total timed code minutes and total treatment time, and the signature and professional identification of the clinician who provided or supervised the service [1]. Your district, clinic or payer may ask for more, so follow your setting's rules.
What is a SOAP note?
SOAP stands for Subjective, Objective, Assessment and Plan. The format grew out of the problem oriented medical record that Dr. Lawrence Weed described in 1968 [2].
Do I have to use the SOAP format?
No. Medicare says the format of treatment notes may vary with the clinician and the setting [1]. In EASI you choose the draft format: a SOAP note, a narrative, or a quick note.
How do I draft session notes in EASI?
- Choose your student.
- Add a session.
- Add your notes: record, add files, type, or use quick marks.
- EASI drafts a full session note in the format you choose.
- Read the draft and change anything you want. It is saved to your student's record.
The video above walks through each step on real EASI screens.
Who reviews the note?
You do. Every note is a draft. EASI drafts, and you read every line and change anything before it is saved to your student's record. The clinician is always in charge.
What else does EASI cover?
EASI covers the range of SLP work: language sample analysis, evaluation reports (in beta), measurable SMART IEP goals, daily notes, progress reports, lesson planning, therapy materials, and caseload management, plus school SLP scheduling software (in beta). EASI is HIPAA and FERPA compliant, with a BAA and insurance.
See EASI therapy notes software.
EASI is made by iTherapy, LLC. Get EASI at NorthernSpeech.com/EASI: https://www.northernspeech.com/EASI
Sources
- Centers for Medicare and Medicaid Services, Medicare Benefit Policy Manual, Chapter 15, Section 220.3 E, Treatment Note. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf
- Weed, L. L. (1968). Medical records that guide and teach. New England Journal of Medicine, 278(11), 593 to 600. https://doi.org/10.1056/NEJM196803142781105