Nice Speech Lady’s most recent resource is a “check-off” list for an outpatient SLP intake process, for a person in private practice or other settings.
Included are the micro-steps, each important for: screening/receiving of the referral, pre-evaluation tasks, all of the way to conducting and submitting an evaluation, first follow-up treatments vs. standard routine treatments — as well as reassessments and the discharge visit.
We can utilize this list to intentionally avoid skipping key activities — all necessary for the intake process, and beyond.
Printable/convenient PDF: HANDOUT-ABLE: Outpatient SLP Intake Guide.pdf
LEADING UP TO THE SLP EVALUATION:
Perform screening encounter & document (if applicable).
If indicated, recommend that the patient request orders directly from their medical provider.
Receive orders for SLP to “evaluate & treat as indicated.”
Create a new patient record in the EMR.
Contact patient/family: state clearly the reason for the visit, per the referral.
Ask for the patient’s and caregivers’ preferred names for the clinician to utilize (relay this to the clinician as well).
Benefits determination (communicate with billing regarding pre-auth/deductibles, if needed).
Ask if there are special considerations or support needs for the process of onboarding services.
Communicate with the patient/family on “good faith estimate” details.
If the patient/caregivers desire to proceed, schedule the evaluation.
Inform the patient/family of any requirements for the new patient appointment:
- For effective testing, we ask that please only have the patient and direct caregivers involved in the patient’s care arrive for the visit.
- Please arrive on time — as the amount of time designated for an evaluation is finite, to allow for overall practice scheduling needs.
- Participants may arrive earlier than the time and utilize the waiting area if needed.
- Following 15 minutes of missing an appointment, if the patient has not arrived, the visit will be rescheduled.
- Please call or text for any visits — as soon as possible if there is a risk of a delay so that troubleshooting & updated scheduling can occur.
- All efforts need to be made to make up visits that are missed within the same week. Participants will be encouraged to make this a priority so that progress can occur.
- Presence of the current medical insurance card is required at the date of visit.
- Please bring related paperwork from other providers, instrumental tests, etc.]
Coordinate availability of new patient paperwork, prepare for the patient/POA/parent to consent regarding:
- Privacy policy forms.
- Case history/medical history forms sharing.
- Notification of special conditions of specific payor limitations (tele-practice for Medicare, if applicable, vs. if pre-authorizations/certifications are needed, etc.).
- Financial policy forms.
- Routine COVID-19 screening/questionnaire forms.
- Consent for in-person vs. tele-practice visits.
- Practice information on availability/scheduling (method for making appointments).
- Other related to the intake/consents.
Clinician: determine enough basic referral concerns/background information to establish a list of starting assessments for the initial evaluation.
Add the patient’s birthday information to a cumulative calendar for tracking events related to the practice.
Add patient/provider information into the referral tracking database.
Upload referral information into the EMR.
Notify the referring provider that the referral was received, that contact was made, and that the evaluation has been scheduled (and when).
EVALUATION APPOINTMENT:
AT VISIT:
Silence SLP/clinician electronics to avoid interruptions.
Introduce SLP to patient/family.
Reiterate the primary reason for the evaluation visit per the referral/gathering of preliminary data.
Obtain scanning/a photograph of the current medical insurance card.
Request/review the signing of consents/forms (if not already conducted prior to the visit).
Receive co-payment/payment for visit, if applicable.
Provide instruction on practice-specific information.
- Where the restroom is located.
- Where to fill out covid screener, moving forward, etc.
- Provide the facility/SLP business card.
- State clinician’s preferred name.
- Method of contact.
- Presence of a confidential “input” box or feedback/suggestion mechanism from anyone involved in service delivery (“Your experience and thoughts on it matter”).
Verify the address & contact information of the patient/family.
Ask that patient/family please silence electronics to avoid interruptions (unless expecting an urgent/emergency call; that this please be stated in advance).
Review/discuss the case history.
Conduct the evaluation.
- Inquire about the over-arching goal of the patient/caregivers (follow-up questions).
- Inquire about the general SLP-specific goal (perform follow-up questions).
- Administer standardized measures, and related tasks.
- Administer PROMs.
- Administer informal tasks, as needed.
- Perform point-of-service documentation as much as possible in the EMR, as clinically appropriate.
- Ask if there are areas of concern that were not queried, asking open-ended questions and providing examples — if needed.
- Discuss formal evaluation recommendations, plan of care, mechanisms to address areas of concern, starting goal areas, etc.
- Receive information on preferences for patients in scheduling, if possible.
- Determine willingness for a home practice program and document details.
- Ask for any updates in insurance or contact information — that it be relayed promptly.
- List the roles of the SLP and the roles of the patient/family for treatment.
- Discuss what to expect at future visits.
- Provide opportunities for questions by the patient/family to be answered & concerns addressed.
- Discuss/establish what the clinician will be responsible for, and what is asked of the patient – in order to make progress toward the patient’s/caregivers’ stated goals.
- Schedule the follow-up treatment visit, if indicated.
FOLLOWING THE EVALUATION VISIT:
Scan in consents, COVID-19 questionnaire, and any documentation provided by the patient into the EMR.
Scan insurance cards into the EMR.
Notify the provider of the conducted evaluation, and state that the evaluation report is pending.
Score testing/assessment measures – add content to the full evaluation report.
Complete a daily note.
Complete the full evaluation report with POC/goals.
Enter CPT codes and ICD-10 codes into the EMR system/report.
Fax (and call) the referring provider, call to follow up to make sure it is received.
Confirm the first treatment visit via the automated system or another method.
Determine tasks for the first treatment visit.
Await/look for a signed POC document from the referring provider.
Communicate with billing regarding pre-auth, if needed.
Scan the signed copy of the evaluation/POC into the EMR.
Check to ensure delivered CPT codes are documented.
“FIRST” FOLLOW-UP VISIT:
Silence SLP electronics to avoid interruptions.
Ask that patient/family please silence electronics to avoid interruptions (unless expecting an urgent/emergency call; that this please be stated in advance).
Administer COVID-19 screening/questionnaire.
Inquire if there are any new concerns since the last visit.
Facilitate in-depth discussion on evaluation results.
Provide an opportunity to discuss areas not covered at the intake visit.
Provide a copy of the full evaluation report if indicated after authorization has been obtained.
Conduct therapy tasks — directly or indirectly.
Perform point-of-service documentation as much as possible in the EMR.
Provide and discuss the rationales for any new recommendations.
Create an opportunity for any questions to be asked/answered.
Schedule the next follow-up visit.
FOLLOWING THE VISIT:
Complete documentation of the daily note
Follow-up with the provider, as needed.
Plan tasks for the next visit, as well as collect materials for conducting activities.
ROUTINE FOLLOW-UP VISITS:
Silence SLP electronics to avoid interruptions.
Ask that patient/family please silence electronics to avoid interruptions (unless expecting an urgent/emergency call; that this please be stated in advance).
Administer COVID-19 screening/questionnaire.
Inquire if there are any new concerns since the last visit.
Ask how the home practice program is turning out.
Conduct therapy tasks — directly or indirectly.
Perform point-of-service documentation as much as possible in the EMR.
Provide and discuss the rationales for any new recommendations.
Create an opportunity for any questions to be asked/answered.
Schedule the next follow-up visit.
FOLLOWING THE VISIT:
Complete documentation of the daily note
Follow-up with the provider, as needed.
Plan tasks for the next visit, as well as collect materials for conducting activities.
REASSESSMENT VISITS:
AT VISIT:
Silence SLP electronics to avoid interruptions.
Ask that patient/family please silence electronics to avoid interruptions (unless expecting an urgent/emergency call; that this please be stated in advance).
Administer COVID-19 screening/questionnaire.
State the nature of the need for a reassessment.
Inquire if there are any new concerns since the last visit.
Re-verify the patient’s/caregivers’ address/ contact information.
Conduct reassessment measures (receive an update of the goal of patient/ caregivers and establish the areas for improvement/interest.
State the positives the patient/caregiver has in place that will assist in reaching goals.
Check in all goals and provide updates.
Ask about new areas to address for the future.
Receive updated information on preferences for the patient in scheduling.
Determine willingness for a continued home practice program and document details, ask how it is going and adjust accordingly.
Re-visit older recommendations & provide/discuss the rationales for any new ones
Create an opportunity for any questions to be asked/answered.
Schedule the next follow-up visit.
FOLLOWING THE VISIT:
Notify the provider, and state that the reassessment report is pending.
Score re-testing/re-assessment measures.
Complete the daily reassessment/encounter note.
Complete the re-assessment report with updated POC/goals, taking care to perform an in-depth analysis of the rationale to continue with services.
Update CPT codes and ICD-10 codes into the EMR system/report.
Fax (and call) the referring provider, call to follow up to make sure it is received.
Determine a plan for the next set of treatment tasks/activities.
Await/look for a signed POC document from the referring provider.
Communicate with billing regarding pre-auth, if needed.
Communicate with insurance on deductibles, etc., if needed.
Scan the signed copy of the reassessment into the EMR.
Check to ensure delivered CPT codes are documented.
Confirm the first treatment visit via the automated system or another method.
Plan tasks for the next visit, as well as collect materials for conducting activities.
SLP DISCHARGE VISIT:
AT VISIT:
Silence SLP electronics to avoid interruptions.
Ask that patient/family please silence electronics to avoid interruptions (unless expecting an urgent/emergency call; that this please be stated in advance).
Administer COVID-19 screening/questionnaire.
State the rationale for the indicated discharge from SLP services.
Inquire if there are any final concerns.
Re-verify the patient’s/caregivers’ address/ contact information.
Conduct discharge reassessment measures & receive an update of the discharge status of goals.
Re-visit the original goals set by the patient, both general and SLP-specific.
Ask about new areas to address for referrals/recommendations.
Share information about conditions that may lead to re-starting SLP services again, in the future.
Follow up on any home program tasks for the patient to continue to implement into their regular schedule, if willing.
Re-visit older recommendations & provide/discuss the rationales for any new ones
Reiterate the primary method of contact for the SLP in the future for any follow-up questions.
Create an opportunity for any questions to be asked/answered.
Thank the patient/caregivers for their hard work and wish them good luck on all endeavors.
FOLLOWING THE VISIT:
Notify the provider, and state that the discharge report is pending.
Score any re-testing/re-assessment measures.
Complete the daily reassessment/encounter note.
Complete the discharge report, summarizing care with the updated/discharge recommendations.
Fax (and call) the referring provider, call to follow up to make sure it is received.
Scan the signed copy of the reassessment into the EMR.
Check to ensure all delivered CPT codes during the scope of visits were accurately documented.
Change the status of the patient to an “inactive” status in the EMR.
Hopefully, this resource is helpful to you, in taking all housekeeping steps — especially in the intake process. Please share if this was helpful!
Wilson Nice, SLP, is the owner of Nice Speech Lady, a medical SLP platform for functional, practical and evidence-based SLP clinical resources.
Nice has been publishing complimentary tools for SLPs since February of 2018.
She is a hybrid outpatient clinic owner — serving adults and children, in Socorro, New Mexico.
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