Strong documentation is one of the most powerful clinical tools a licensed professional has, yet it is often one of the more challenging areas of practice. When working with oral motor, feeding, oral placement and orofacial myofunctional disorders, clinicians must synthesize complex findings across structure and function into reports that are clear, evidence based, and meaningful to both families and interdisciplinary teams.
This focused 2-hour course is designed to help clinicians refine and elevate their documentation skills for oral motor, feeding/swallowing, oral placement and orofacial myofunctional based evaluations and treatment. Using a practical, real-world approach grounded in evidence-based practice and the 4 MYODomains™ framework (airway, feeding/swallowing, structure and speech), participants will learn how to organize findings, interpret clinical data, and write reports that clearly support diagnosis, medical necessity, and intervention planning.  
In addition, emphasis will be placed on translating clinical observations into defendable reports, eliminating vague or non-specific language, and developing measurable, goal-driven plans of care. Additional discussions will include progress reports, letters of medical necessity, documentation and justification for educationally based services and interdisciplinary communication. Through guided examples and applied strategies, participants will leave with tools they can immediately implement in their own practice.
NOTE: This course is written from the perspective of a speech-language pathologist but can apply to occupational and physical therapists’ documentation as well.

Participants will be able to: 

1. Describe at least 3 components of a comprehensive evaluation report
2. Differentiate between subjective findings and objective interpretation in documentation.
3. Demonstrate strategies for documenting medical necessity and educational impact.
4. Compare effective vs. ineffective documentation practices in evaluation reports and data.

Instructor Details and Financial Disclosure 

• Robyn Merkel-Walsh, MA, CCC-SLP, COM®️

Registration Fees

• $150  0.2 ASHA CEUs, digital workbook & certificate of completion.

Schedule

Timed Agenda

• Background and Learner Objectives - 20 minutes
• Module 1: Foundations of Documentation - 20 minutes
• Module 2: Structuring the Evaluation Report - 20 minutes
• Module 3: Writing with Purpose - 20 minutes
• Module 4: From Data to Diagnosis - 20 minutes
• Module 5: Goal Writing and Plan of Care - 20 minutes
• Module 6: Medical Necessity, Progress Reports and Interdisciplinary Communication - 20 minutes
• Module 7: Case Studies and Report Analysis - 20 minutes
• Summary and Q&A - 20 minutes 

Total: 180 minutes 

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Content Disclosure: This presentation will focus on treatment methods related to the use of TalkTools® resources. Other similar treatment approaches will receive limited or no coverage during this lecture.

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