Patient/Caregiver Home Program & Education Plan (SLP)

Patient/Caregiver Home Program (Speech-Language Pathology)

Date: [date of visit]

Clinician: [name and credentials]

Clinic: [clinic/site name]

Questions? Call [phone number] during [hours]. For emergencies, call 911.

(Include the next line only if a caregiver/family member will primarily carry out the plan.)

This plan is for: [Patient full name] and [Caregiver/Family name or role].

Your Main Takeaway Today

[1–3 short sentences summarizing the highest-priority behavior or safety item. Bold the single most critical safety instruction.]

• [Item 1 from today's session] → [Specific home action or safety behavior]
• [Item 2 from today's session] → [Specific home action or safety behavior]
• (Include only if addressed) [Item 3] → [Home action or safety behavior]
• (Include only if addressed) [Item 4] → [Home action or safety behavior]

(If session details are unavailable, replace bullets with: "Today's home plan is based on your current goals and safety needs. Please contact us if anything here looks unfamiliar.")

Your Home Practice Plan

(Only include activities practiced and agreed upon today. If dosage cannot be safely specified, write: "Practice with supervision only—ask your SLP for exact amount.")

Task name	How often	How much	When to practice	Equipment/notes	Stop rules
[Task 1 name]	[days/week]	[sets/reps/minutes]	[time of day or cue]	[items needed / none]	[stop rule / none]
[Task 2 name]	[days/week]	[sets/reps/minutes]	[time of day or cue]	[items needed / none]	[stop rule / none]
(Include additional rows as needed for tasks addressed)

Swallowing and Mealtime Safety

(Include this section only if swallowing was addressed today.)

• Current diet/liquid level: [Facility/IDDSI level] — [plain-language explanation]
• Positioning: [specific positioning instructions and when to use]
• Pacing: [bite/sip size, swallows per bolus, rate guidance]
• Compensation strategies: [strategy name] — [when to use], [how to do it], [common mistakes]
• (Include if relevant) Oral care: [timing and steps]

Do not change your diet unless your medical team tells you to.

(If diet level is unknown: "Continue your current diet plan. Contact us if unsure.")

Speech Clarity

(Include this section only if speech clarity was addressed today.)

• Key strategies: [1–3 strategies in plain words]
• Structured drill: [drill name and instructions with dosage]
• Real-life carryover: [specific daily situation to use strategy]

Voice

(Include this section only if voice was addressed today.)

• Vocal hygiene: [hydration goal], [irritants to avoid], [voice rest guidelines]
• Exercises: [exercise name] — [dosage and technique]
• Stop rules: Stop if you feel [pain / strain / dizziness / shortness of breath]; [patient-specific additions]

Language/Aphasia Strategies

(Include this section only if language/aphasia was addressed today.)

• For you: [patient strategies: gesture, point, write key words, use photos]
• For your partner: [reduce distractions, give extra time, ask yes/no, confirm understanding]
• Repair plan: If communication breaks down: [step 1], [step 2], [step 3]

Memory, Attention, and Organization

(Include this section only if cognition was addressed today.)

• Daily routine support: [one habit/cue tied to daily routine]
• Environment: [one change to reduce distractions or improve organization]
• Caregiver cue: [simple prompt and when to use it]

AAC/Communication Device

(Include this section only if AAC was addressed today.)

• Daily care: [charging schedule, case/positioning, cleaning]
• Core words to practice: [5–15 words/phrases] — [brief practice instructions]
• Partner support: [model on device, wait time, confirm message, encourage attempts]
• Troubleshooting: [steps to check power, volume, access method, connections]
• Backup plan: If device unavailable: [paper board / notebook / gesture / yes–no method]

Teach-Back Confirmation

Who taught back: [patient / caregiver / both]

Method: [verbal explanation / return demonstration / both]

Result: [accurate / partially accurate / not yet accurate]

(If partially or not accurate: [what was re-taught], [supports added such as visuals, cues, or practice trials])

(If patient could not participate: [barrier], [adaptation used]. Do not infer comprehension.)

Stop and Get Help If...

Call 911: Severe trouble breathing, choking that does not resolve.

Call your doctor:

• [Condition-relevant red flag in plain language]
• [Condition-relevant red flag]
• [Most important doctor alert for this patient — bold this one]

Call our clinic ([phone number]):

• [New or worsening coughing during meals]
• [Wet or gurgly voice after drinking]
• [Unable to complete exercises safely]
• [Device or equipment failure]
• [Caregiver concerns or unable to carry out plan]
• [Questions about this plan]
• [Most important clinic trigger for this patient — bold this one]

Next Steps

Next visit: [date/time] (or "Please call [number] to schedule.")

What to bring: [glasses / hearing aids / communication device / thickener / written questions — as relevant]

What we'll work on next: [brief preview of next session focus]

(If materials provided, list here: [Handout/Video/Equipment titles and language]. Omit if none.)