Speech-Language Pathology Plan of Care (Outpatient Therapy)

Header Block

Patient Name: [Full name] | DOB: [Date of birth] | MRN: [Medical record number] | Preferred Language: [Language] (Note interpreter need if applicable)

Document Status: [Initial POC / Updated POC / Recertification POC]

Referring Provider: [Name, credentials, NPI, contact/fax] | Primary Care Provider: [Name if different from referring]

Dates: Evaluation Date [Date] | POC Established [Date] | First Treatment [Date] | Certification Period [Start–End] | Recertification Due [Date]

Planned Frequency/Duration: [Frequency, duration, session length, and mode (in-person/telepractice)] (If tapering anticipated, document starting frequency and taper plan. If not yet determined, state "Pending.")

Diagnoses & Medical Necessity

• Medical Diagnosis(es): [ICD-10 codes with descriptions] (Distinguish confirmed diagnoses from unverified referral diagnoses)
• SLP Treatment Diagnosis(es): [Communication or swallowing diagnosis using standardized terminology]
• Onset/Date of Event: [Date if known and relevant]
• Prior Level of Function: [Communication and/or swallowing function before onset or decline]
• Current Functional Limitations: [Participation restrictions and safety/efficiency impacts on daily activities]

Skilled Need Statement: [3–6 sentence justification explaining why skilled SLP services are required rather than caregiver-only support, expected trajectory (improvement/maintenance/prevention of decline), and supporting factors including severity, stimulability, comorbidities, and barriers. Frame prognosis as clinical judgment with rationale.]

Evaluation Summary

(Provide minimum baseline to justify goals and interventions. If full evaluation exists separately: "See SLP Evaluation dated [Date].")

• [Pertinent medical/surgical/behavioral history affecting therapy]
• [Key objective findings and severity indicators]
• [Standardized assessments with scores or clinically meaningful descriptors]
• [Safety-relevant findings (aspiration risk, cognitive safety concerns)]
• [Environmental/personal factors impacting outcomes]

Problem List

(Include only domains assessed and impaired. Use stable identifiers P1, P2, etc. Possible domains: Speech, Language, Cognitive-Communication, Voice/Resonance, Fluency, Swallowing/Feeding, AAC/Communication Supports.)

• [Domain]
  • P1: [Problem statement] | Functional consequence: [Impact on daily activities] | Baseline: [Quantitative measure]
• [Domain]
  • P2: [Problem statement] | Functional consequence: [Impact] | Baseline: [Measure]

(Add additional problems as applicable. If domains were deferred: "Not assessed this episode: [domains].")

Progress Since Last POC

(Include for Updated or Recertification POCs only; omit for Initial POCs.)

• P1: [Progress summary with current data vs. baseline; response to interventions]
• P2: [Progress summary]

Goals

(Organize by problem identifier. Order by: safety risk, functional impact, patient priorities. Each goal specifies behavior/target, functional context, assistance level, quantification, timeframe, and measurement method.)

P1 Goals

• LTG: [Functional outcome] — [Assistance/cueing level] — [Quantification] — [Timeframe] — [Measurement method]
• STG 1: [Measurable stepping-stone skill/behavior] — [Assistance level] — [Quantification] — [Timeframe] — [Measurement method]

P2 Goals

• LTG: [Functional outcome] — [Assistance level] — [Quantification] — [Timeframe] — [Measurement method]
• STG 1: [Stepping-stone skill] — [Assistance level] — [Quantification] — [Timeframe] — [Measurement method]

(Continue for additional problems. Goals must reflect functional outcomes, not therapy processes.)

Treatment Plan

(List skilled interventions by problem with rationale linking to impairment and functional target.)

P1 Interventions

• [Intervention type] — [Rationale: how this addresses functional target]
• [Intervention type] — [Rationale]

P2 Interventions

• [Intervention type] — [Rationale]
• [Intervention type] — [Rationale]

(Intervention types may include: therapeutic exercises, strategy training, AAC evaluation/training, caregiver training, environmental modifications, home program, interprofessional coordination.)

Safety Precautions

• [Swallowing precautions: positioning, pacing, supervision level]
• [Diet/liquid recommendations or reference to diet order]
• [Cognitive/behavioral safety considerations]
• [Voice use precautions]
• [Medical restrictions relevant to therapy]

(Include only applicable precautions. If none identified: "No therapy precautions identified.")

Patient/Family Education & Home Program

• Education provided/planned: [Topics: diagnosis, strategies, device training]
• Home program: [Activities, frequency, supports required]
• Understanding demonstrated: [Teach-back results; materials provided]
• Adherence barriers/mitigation: [Anticipated barriers and plan to address]
• Caregiver role: [Expected tasks and supports]

Discharge Criteria & Plan

• Discharge Criteria: [Goal attainment / Plateau / Independent strategy use / Safety stabilization]
• Anticipated Disposition: [Home program only / Community program / Transfer of care / Maintenance plan]
• Anticipated Timeframe: [Estimated discharge date or range]
• Maintenance/Generalization Plan: [How gains will be sustained post-discharge]

Coordination of Care

• POC recipients: [Referrer, PCP, specialists]
• Status update schedule: [At recertification / At discharge / As needed for safety changes]
• Interdisciplinary coordination: [Planned actions with other providers]

Certification

Establishing Clinician: [Name, credentials] — Signature: ______________ — Date: [Date]

"Plan of care established on [Date]."

Certifying Provider: [Name, credentials, NPI] — Signature: ______________ — Date: [Date]

[Certification statement acknowledging review and approval of plan]

(If using order/referral for initial certification: Document POC transmission—date sent, method, recipient, confirmation.)

(If signatures pending: "Pending signature — sent [Date/Time] — follow-up plan: [Plan]")

Recertification Due: [Date]