Speech pathologists: let’s improve our progress notes to help our clients – and ourselves

Why it matters:

Writing good file/progress notes of our consultations is:

required by our Professional Standards, Code of Ethics, Statutory Code of Conduct and NDIS Code of Conduct; and
helpful if a complaint is made against us or if we are sued, e.g., for professional negligence.

Case in point:

D Lane v Northern NSW Local Health District [2013] NSWDC 12

Zoom in:

Good progress notes are:

accurate;
objective;
respectful;
contemporaneous;
up-to-date;
legible;
complete;
securely-stored; and
kept for at least the minimum period required by law (e.g. in NSW, 7 years after last service or when a child client turns 25, whichever is later).

Yes, but:

Good note taking takes time and energy. You need a system to ensure progress note-taking fits into your daily workflows and doesn’t get on top of you.