Two notes for the same session. The first says: "Worked on /r/. Student did well. Continue." The second says: "Targeted /r/ in words at the initial position. 14 of 20 correct with a verbal cue on 6. Accuracy up from 9 of 20 two weeks ago. Next: move to phrases." The second took ninety seconds longer to write and it is the only one a reviewer can use.
This guide breaks a session note into four parts so you can write the second kind quickly.
What a note has to do
ASHA's guidance on documentation in schools says treatment notes should let a reviewer see why the treatment was given, what it involved, the student's current status, and the next steps. Activities should match the IEP goals, and notes should record the minutes of service and whether the student attended. It also asks for both a qualitative and a quantitative description of performance.
That is a good test for any format. If a colleague who never met the student can answer those four questions from your note, the note works.
The four parts
| Part | What goes here | Do | Avoid |
|---|---|---|---|
| S, Subjective | What the student, teacher, or parent reported, and your brief context | One or two facts, with source | Guesses about family circumstances or motives |
| O, Objective | What you observed and measured | Task, count and total, cue level, setting | Raw impressions such as "went well" |
| A, Assessment | What the data mean for the goal | Comparison with the last session or the baseline | Claims the data cannot support |
| P, Plan | What happens next and when | The next target, any change in cues or materials, who needs to know | A plan that does not follow from the assessment |
S: Subjective
Keep it short and sourced. "Teacher reports the student asked for help twice in class this week." "Student said the group activity was too hard." If there is nothing to report, you can leave it brief.
O: Objective
This is the most important part to get right. It holds the numbers and the conditions: the task, the number of correct responses and the total, the type and number of cues, and the setting. ASHA's page notes that raw tallies and check marks are generally not part of the designated record set, while the interpreted summary, such as "completed cloze sentences with 70% accuracy with minimal cues," is part of the record. So write the summary, not the tick marks.
A: Assessment
Say what the numbers mean for the goal. This is where you compare today with the baseline or the last session and say whether progress is steady, flat, or slower than expected. Keep it to what the data support.
P: Plan
Name the next target and any change in cueing or materials. If something needs to go to the teacher or the team, say so here.
Two invented examples
| Part | Entry |
|---|---|
| S | Teacher reports the student used the target sound in class presentations this week |
| O | Group, 30 minutes. Target /r/ in initial position of words. 14 of 20 correct, with a verbal cue on 6 trials. Two weeks ago: 9 of 20 |
| A | Accuracy up 5 trials in two weeks, with fewer cues needed. On track for the annual goal |
| P | Move to two-word phrases next session. Fade verbal cue to a visual cue |
| Part | Entry |
|---|---|
| S | Student reported liking the story and did not want to stop |
| O | Individual, 20 minutes. Retell of a short story with 3 target past-tense verbs. Used 2 of 3 correctly, with a verbal prompt for the third. Baseline: 1 of 3 |
| A | Slight gain over baseline. Needs prompt for irregular verbs |
| P | Add irregular verbs to picture practice. Send teacher a list of 3 verbs to listen for |
Each entry could be written in under two minutes if the data sheet is already filled in.
Time-savers
- Pre-fill the header: student code, date, group or individual, and the goal numbers.
- Write the number of trials and the correct count while you work, so O is a copy and not a recall.
- Use sentence starters that you have approved with your supervisor, and edit them every time. Copied notes with only the date changed can mislead the next reader.
- Finish notes the same day if you can.
Identifiers, signing, and dating
ASHA recommends using initials in place of students' names and avoiding identifiers such as date of birth or address when possible. Student identification numbers help prevent mix-ups. FERPA's definition of identifying information is broad, so follow your district's own coding policy. Sign and date notes the way your district requires. If you take phone calls or send messages about a student, note the date, including the year, and who took part, and know that email and text are generally not secure for discussing student information.
Group sessions
For groups, write one entry for each student, using only that student's data, so that no family reads about another child. Our guide on group session notes without naming other students has a per-student template. The same four parts apply: what the student reported, what you measured for that student, what it means for that student's goal, and what you will do next for that student.
Late entries and corrections
If you add to a note after the fact, add the new text with its own date and mark it as a late entry, rather than rewriting what was there. If you made an error, correct it in the way your district allows, which often means a dated correction beside the original rather than a deletion. Your district's policy governs, so ask your supervisor how corrections are handled.
If the note supports a Medicaid claim
A note that is also part of a billing record needs the date, start and finish times, who provided the service, what the service was, and where. See school Medicaid documentation basics. For layouts for the numbers, read the progress data sheet guide. For what the privacy rules mean for your notes, see FERPA and session notes. Terms are in the glossary.