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Hysio Speech and Language Therapy
Discover the report layout for consultation, intake, examination and evaluation. Each format keeps voice, speech, language, hearing and swallowing with the right source role, so you decide what goes into the record.
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Hysio turns spoken information into a report. Choose the report format for the conversation you are documenting.
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Four formats for treatment, intake, examination and evaluation across different communication domains.
For speech and language therapy, this profile has four documentation formats: consultation, intake, examination and evaluation. The layout keeps voice, speech, language, hearing and swallowing with the right source role, so that examination results, treatment progress and the client's perspective do not get mixed up.
For speech and language therapy there are four formats: consultation, intake, examination and evaluation. The choice follows the phase and the communication domain of the contact. This keeps treatment, referral, test results and goal attainment clearly separate from one another. You assess the source role, terminology, conclusion and what is finally saved. Each format has its own heading structure, so that a treatment report is never read as an examination report and a test result does not end up as a treatment outcome. In this way, voice-driven reporting follows the methodical approach of speech and language therapy, from first contact to evaluation. [2] [3] [4] [5] [7] [8]
This format turns a treatment or follow-up contact into a clear speech and language therapy daily journal. It keeps the course of the complaint, the voice, speech, language, hearing or swallowing treatment, the evaluation, agreements and any consultation with others that actually took place clearly apart. The date, the treatment given, a different duration or location, adjustments and consultation with others only appear in the text when they were mentioned in this contact. Before transferring it to the record, assess which information actually comes from the contact. [2] [8] [6]
This format organises a first speech and language therapy contact from registration and care request to history, examination, professional analysis and a discussed treatment plan. The layout has fixed sections: summary, registration and route, speech and language therapy history, speech and language therapy examination, speech and language therapy analysis, treatment plan and Hysio Supplementary. Perceived and measured functioning, external source information, goals, dosage, agreements and consent stay linked to the client, those involved, the referrer or the practitioner. [3] [6] [7]
This format turns a targeted first or repeat speech and language therapy examination into a report with the examination question, the sections actually carried out, the exact results and the speech and language therapy analysis and conclusion you stated. The sections appear in a fixed order: summary, examination question and context, examination performed, examination results, speech and language therapy analysis, speech and language therapy conclusion and Hysio Supplementary. A section that was not administered stays visibly empty. [4] [7] [8]
This format turns an interim or final evaluation into a report of speech and language therapy goals, treatment progress, measurement results, both perspectives, follow-up and aftercare. The result according to the client and the result according to the speech and language therapist appear in separate sections, so that they are not merged into one judgement. At discharge, the reason for ending care, the aftercare and the agreements each appear separately. Assess whether every conclusion can be traced back to recorded information. [5] [8] [6]
The consultation report is intended for a treatment or follow-up contact that centres on the course of the complaint, the tasks carried out, the response to the session, home exercises and agreements. A first broad history belongs in the intake and a separate test administration in the examination report. This keeps treatment progress and examination apart. The speech and language therapist assesses whether each section was actually discussed or carried out during this contact. [2] [6] [7]
In the intake, Hysio links the care request and experiences to the client, information from parents, school or others involved to the client system, and the referrer, referral date and reason for referral to the referral. Observations, test findings, analysis and treatment plan stay recognisably those of the speech and language therapist. This lets you check for each section who the source is, and a statement from a parent does not appear as your professional finding. [3] [7] [8]
The examination report is intended for a contact in which a targeted first or repeat assessment is central, not just a treatment activity. Record the examination question, the testing context, the sections actually carried out, the exact results and an explicitly stated professional conclusion. A test that was not administered or a missing norm score stays out of the text. This keeps the examination separate from intake and evaluation, and the format keeps question, administration and conclusion apart. [4] [8] [6]
For speech and language therapy there are four documentation formats: consultation, intake, examination and evaluation. They follow the methodical speech and language therapy process: registration, history, examination, analysis and treatment plan come together in the intake, the treatment carried out in the consultation, a targeted administration in the examination, and goal attainment, discharge and aftercare in the evaluation. As a result, an examination outcome never appears as a treatment result. [2] [3] [4] [5] [8] [6]
A consultation organises the course, the treatment carried out, the evaluation and the agreements of a follow-up contact. An intake organises registration, speech and language therapy history, examination, analysis and treatment plan. Hysio does not silently swap one format for the other. You choose the documentation format and assess whether the content matches the contact that actually took place. [2] [3] [6] [7]
Logopedist (speech and language therapist) is a protected training title under article 34 of the Wet BIG. Unlike article 3 professions, there is no registration in the BIG register and no BIG number attached to it. The title protection has applied since 1997. In public information or information in the record, state the professional status carefully and do not suggest that a speech and language therapist is listed in the BIG register because of this title. [1] [6] [7]
Registration in the Kwaliteitsregister Paramedici is not a legal requirement for speech and language therapists, but in practice it is the norm for contracted primary care and for demonstrable continuing professional development. The registration has a re-registration cycle of five years. Only mention the KP registration in the record when it is current and verifiable. The quality register does not replace checking the record: the speech and language therapist remains responsible for source roles, professional content, consent and the final text that goes into the record. [1] [7] [8]
The professional profile names independent practice as the main setting: most speech and language therapists work in independent practice, as care professionals and/or entrepreneurs. Speech and language therapists also work in health centres and in care institutions: hospitals, residential care homes, nursing homes, rehabilitation institutions, mental health care institutions, audiology centres, institutions for disability care and medical day-care centres for children. Because the setting determines who takes part in the conversation, you keep it visible for each contact whether information comes from the client, a parent, a teacher or a referrer. [1] [8] [6]
At Hysio, the general individual Starter plan starts at €20 per month excl. VAT. Pro costs €40 and Unlimited €80 per month excl. VAT; with yearly billing you pay for ten months instead of twelve. The price applies per person and is independent of the profession. On the pricing page, compare the current terms, the contact volume and the expected review time before you make a choice. [1] [9]
Only process data that is necessary for the care purpose and pay extra attention to information from parents, school, the referrer or others involved. Make agreements about recording, access, source roles, approval and transfer to the record. Hysio processes this data as a processor; the practice remains the controller. Use the current privacy policy and legal information for the exact processing and terms. [1] [11]
Arrange the introduction on paper first and only then in client contacts. Decide in advance who reviews source roles, terminology and agreements, and how privacy and transfer to the record are handled. Only add the examination once test name, testing conditions, score and professional conclusion reliably stay separate. Then expand in a controlled way to intake and evaluation, with human approval of every report text. [1] [11] [12]
In an evaluation you record the goals assessed, the treatment progress, available measurement results, the client's perspective and your professional conclusion. Make clear whether it is an interim moment or a discharge. Follow-up, aftercare and the date of reporting to the referrer only appear when they were discussed during this evaluation. The evaluation report remains an internal record document; you write a letter to the referrer separately. [5] [6] [7]
A speech and language therapy follow-up consultation gets a fixed order: first the course and the client's experiences since the previous contact, then the voice, speech, language, hearing or swallowing tasks carried out, then your evaluation, then the agreements and finally any consultation with others. This order makes it visible afterwards what you did and what you decided next. A new examination result only belongs in the daily journal when it was established during this session. [2] [7] [8]
A speech and language therapy examination names the domain, the task or instrument used, the testing conditions, the moment of measurement and the outcome as stated. There is no mandatory national measurement set; the choice depends on the area of complaint. This keeps the professional content of the test administration separate from the interpretation you give it. Hysio does not invent a test result, normative comparison or conclusion when it is not in the source. In AI reporting, that is the core: only what you name goes into the report. [4] [7] [8]
The evaluation is intended for the moments when you discuss goal attainment: at the periodic review of the main goal and at the end of the treatment programme. A single observation during a treatment belongs in the consultation report. Hysio does not fill in improvement or stagnation based on an earlier expectation and does not turn a treatment observation into a completed evaluation. [5] [8] [6]
The speech and language therapist does not belong to a BIG-registered profession subject to disciplinary law. Logopedist is an article 34 profession under the Wet BIG: the training title is protected by law, but there is no registration in the BIG register. For your record this changes little, because the duty to keep records does not follow from the Wet BIG but from the Wet op de geneeskundige behandelingsovereenkomst (Dutch Medical Treatment Contracts Act). Accountability therefore runs through the professional guideline, the quality register and contract agreements instead of through BIG disciplinary law. [1] [8] [6]
The authoritative guideline is the NVLF-Richtlijn Logopedische Dossiervorming 2019, version 2.0, dated July 2019, published by the Nederlandse Vereniging voor Logopedie en Foniatrie (NVLF). It replaces the 2016 version and no successor has been published, so this is the current guideline for speech and language therapy record keeping. Also check your record text against the agreements your own organisation uses. [1] [6] [7]
The publication date of the NVLF guideline's content is July 2019; the accompanying summary card dates from June 2019. The file path on the NVLF website contains 2024, but that points to a later upload and not to a new guideline version. So assess the title, date and content of the primary source instead of taking the year in the URL as the version date. [1] [7] [8]
The guideline on speech and language therapy record keeping is aimed at speech and language therapists in special primary education, preventive speech and language therapy, primary care and inpatient healthcare. That broad scope calls for a record that keeps the field of work and the source context recognisable. Only apply sections that belong to the contact that took place, and always check whether your organisation uses additional agreements. [1] [8] [6]
The NVLF guideline describes the speech and language therapy diagnosis as the profession-specific judgement on which advice about treatment or referral to another professional is based. It does not necessarily have to be written as a continuous narrative. The professional reasoning must, however, remain traceable and be clearly distinguished from the client's report, test results and information from an external source. [1] [6] [7]
For the journal entry per session (step 6), the guideline names three equivalent systems as examples: SOAP, SOEP and SOEPI, where the I stands for instructie (instruction). The choice is up to the speech and language therapist and none of the three is mandatory. Note that in speech and language therapy SOEP, S and O refer to the subjective and the objective treatment result, not to the complaint and the finding as in physiotherapy. Hysio's speech and language therapy documentation formats use named headings and no letter scheme. [1] [7] [8]
The guideline itself names a direct link between record keeping and the contract with the health insurer. Because insurers have to purchase care of sound quality, the contract that the health insurer and the speech and language therapist conclude increasingly includes a quality clause, which assumes documentation in line with the guidelines of the profession. Your record is therefore also the substantiation of that quality agreement. [1] [8] [6]
For a referred client, information from the referrer may be needed to understand the care request and the medical context. Record the referrer, referral date and reason for referral as a separate source role. Only request what you need for this care question, make purpose and origin visible and follow your organisation's consent agreements. A referral is not general consent for unrestricted data exchange. [1] [6] [7]
Name the domain that was actually discussed or examined in the contact and link observations to the right activity or communicative situation. Voice, speech, language, hearing and swallowing can affect one another, but they are not the same. Hysio organises the terminology used and does not create a broader description of the disorder than the source supports. With voice-driven admin, name the domain out loud, and the report stays readable per domain. [3] [4] [6] [7]
The client's perspective describes the experienced complaint, care request, goals, expectations or response to treatment in its own source role. It sits alongside the observation and professional assessment of the speech and language therapist and is not mixed with them. Hysio does not turn what a client reports into an objective examination outcome and does not attribute a professional conclusion to the client. For a child, a parent's statement remains a separate source role. [2] [3] [5] [7] [8]
A speech and language therapy intake starts with registration and care request and then organises history, perceived functioning, any examination findings, professional analysis, goals and treatment plan. The registration route is explicitly part of it: direct access or referral, and with referral also the referrer and the reason for referral. Goals, dosage and agreements only appear when they have been discussed. You assess whether each section belongs to this first contact and is complete enough for the record. [3] [7] [8]
Hysio Speech and Language Therapy Examination turns a targeted first or repeat speech and language therapy examination into a report with the examination question, the sections actually carried out and the exact results. In the methodical process, the examination sits between the history and the speech and language therapy analysis: it provides the data on which you base your conclusion. The report records that step separately, so that it stays visible later which finding came from the administration and which interpretation you stated afterwards. [4] [8] [6]
The evaluation report shows which goals were followed, which result was achieved, how the client experiences the treatment programme and which follow-up was professionally determined. It links a measurement outcome to the instrument and the moment of measurement without deriving improvement or stagnation itself. At discharge, the reason for ending care, the aftercare and the relapse agreements stay separately recognisable. The purpose is accountability for the treatment programme, not a new diagnosis. [5] [6] [7]
A usable daily journal names the current treatment goal, the task carried out, relevant observations, the perceived response and the follow-up in a logical timeline. Terminology stays linked to the domain that was actually covered. This lets the next reader distinguish what the client reported, what you treated and which agreement is still open. With voice-driven reporting, you briefly dictate those points after the session. [2] [7] [8]
After an intake, Hysio delivers an organised result with the care request, relevant history, source information, findings, analysis, goals, agreements and the discussed treatment plan. Details that were not mentioned are left out. Then assess whether client statements and professional interpretation are correctly attributed, whether consent is listed separately and whether the chosen wording fits the actual contact before you save the text. [3] [8] [6]
The structure starts with the question and the context, followed by the tasks or instruments used, the testing conditions, the results, the speech and language therapy analysis and finally the conclusion. A measured value only gets a norm or comparison when that comes explicitly from the source. Observation and conclusion stay separate, so that it can be traced afterwards which finding came from the test and which interpretation you established. [4] [6] [7]
An interim evaluation fits when you discuss goal attainment, treatment progress and any adjustment while the treatment programme continues. A final evaluation is intended for the moment when the reason for discharge, aftercare and relapse agreements are also covered. In both cases, measurement results, the client's perspective and professional assessment stay separately visible. Hysio does not declare a goal achieved and does not close a treatment programme without explicit source information. [5] [7] [8]
The report of a follow-up consultation covers what changed since the previous contact, which voice, speech, language, hearing or swallowing tasks were carried out, how the client responded and what was agreed for home or the next contact. Only dosage, aids and consultation with others that were actually discussed are included. New examination conclusions or goals do not appear automatically. The speech and language therapist safeguards the source role, timeline and the final wording in the record. [2] [8] [6]
No. Isolated words do not produce a speech and language therapy diagnosis in Hysio. An analysis or conclusion is only included when you state it as a professional source. Terms about intelligibility, voice, language or swallowing are not a diagnosis in themselves. Hysio can organise source information, but keeps missing substantiation visible and does not turn a hypothesis into an established conclusion. The line is drawn by who makes the statement, not by the word used. [4] [8] [6]
Record which instrument or which observation was used, when the result was obtained and what the outcome means according to the source. If a measured value, norm or comparison moment is missing, you leave that section out or name the gap. Hysio does not create a score and does not calculate progress without recorded data. [4] [5] [6] [7]
The report does not go into your record system automatically. Hysio does not write the report text directly to an electronic health record (EHR) system, because there is no direct integration. You review the text and transfer relevant sections yourself according to your practice's way of working. For an intake, these can be the care request, history, findings, analysis, goals and agreements. Ask your record system supplier which transfer route is possible; this page does not promise a specific integration. [3] [13] [12]
In a speech and language therapy examination, Hysio only takes over the instrument, the task, the testing conditions, the moment of measurement and the result as literally mentioned. A test carried out without a stated result does not get an invented score. Hysio does not calculate ratios, percentiles or norms and does not draw its own conclusion. The speech and language therapist decides which findings and professional interpretation belong in the examination report. [4] [7] [8]
Review every report text against the recording or your notes and keep the client's report, observation, test result and professional conclusion apart. The report text may contain errors, especially with technical terms, negations, testing conditions, scores and norms. A result that was not stated stays missing. The speech and language therapist corrects the text, determines the professional meaning and only approves what belongs in the record. [5] [12]
You can write by hand, use your own template, use general dictation or choose a specialised platform. Working manually can suit a short contact or an unclear recording. A general dictation tool does produce text, but no separation between the client's report, test result and professional conclusion. Compare alternatives on terminology, speaker roles, test data, correction time, privacy and record transfer, not only on transcription speed. [2] [12]
The intake keeps the client's report, information from a parent or the client system, details from the referrer and observations or assessment by the speech and language therapist recognisable as separate sources. Consent is not a catch-all here: agreement to consultation with others, to data sharing and to the treatment plan are three separate decisions, each with its own moment and wording. Hysio does not move an external statement into the professional analysis. [3] [7] [8]
Hysio has a free trial of fourteen days, with no credit card required upfront. Compare several contact types and domains on intelligibility, speaker attribution, technical terms, normative data, follow-up agreements, correction effort and usefulness for your own record. For each contact, check which source belongs with each statement and which text you still correct before you transfer it. Do not add missing data yourself. [4] [10] [9]
No time savings have been measured for the speech and language therapy formats, so measure it yourself. Take recording, generating, listening back, correcting and transferring together as one route. Compare a simple consultation with an intake or examination involving several speakers, technical terms and test data. Note errors and missing source roles as well as minutes. That way you see what admin with AI really saves in your own practice, regardless of recording quality or domain. [5] [12]
After a speech and language therapy consultation, Hysio only records exercises, frequency, duration, stop criterion, aids and follow-up that were actually discussed. A task carried out in the session stays separate from a home agreement. Agreement to practise at home is not consent for consultation with others or data sharing. The speech and language therapist assesses the dosage, source status and final record text. [2] [7] [8]
The four speech and language therapy formats are aimed at consultation, intake, examination and evaluation. They do not create a standalone referral letter outside that set. When information for a referrer has been discussed, that source-bound information can return in the appropriate report. Reporting to the referrer at discharge remains a separate document that you write and send yourself. This keeps the line between record text and correspondence visible. [2] [3] [4] [5] [7] [8]
Assess whether the question, the complaint, the treatment or test carried out, the results, the conclusion, the goals and the agreements belong to this contact. Pay extra attention to negations, speaker attribution and the domains of voice, speech, language, hearing and swallowing. Finally, check whether each conclusion has a source in the text; you decide which wording ultimately goes into the record. [2] [4] [5] [8] [6]
Hysio creates the report. You remain responsible for what you save in the record.