Create clinical reports and IEPs

GoalCopy Anchor Link

Create defensible, audit-ready clinical documentation: comprehensive speech-language evaluations, IEP annual goals, re-evaluation reports, Medicaid encounter logs, or AAC funding justifications. The platform synthesizes client history, goal trends, and clinician-entered assessment scores into structured clinical records.

Before you startCopy Anchor Link

Two doors lead into the document builders:

1. Client Profile (/dashboard/patients/[id] → Documents tab): Recommended. Pre-fills the child's name, birthdate, chronological age, current IEP goals, and recent session accuracy data automatically.
2. Documentation Hub (/dashboard/paperwork): Best for starting a blank template directly or drafting caseload-level forms (e.g. mass screening, general consent). You can link a client at any time.

StepsCopy Anchor Link

1. Pick the template: Go to Documentation (/dashboard/paperwork) or your client's Documents tab. Select the document type:
   • IEP Builder: Annual measurable goals, service minutes, accommodations, and transition plans.
   • Speech-Language Evaluation Report: Private-practice or diagnostic evaluation with developmental history, standardized scores, domain analysis, and plan of care.
   • Re-evaluation Report: Triennial review summarizing progress across previous reporting periods.
   • Session Logger: Medicaid daily encounter note with CPT codes, attendance, and digital signature pad.
   • Student Session Log: School-based service log with monthly minute tracking.
   • AAC Funding Report: SGD evaluation and statement of medical necessity.
2. Review pre-filled client facts: Confirm the client's name, birth month/year, chronological age (calculated automatically relative to today), and active goals.
3. Fill in assessment measures & questionnaire:
   • For evaluations: Enter standardized assessment names and standard scores (e.g. GFTA-3, CELF-5). The AI reports only tests you administered—it never invents subtest scores.
   • For Medicaid logs: Select delivery mode (Individual vs Group), CPT code, and duration in minutes.
4. Draft the document: Click Generate (or start with a structured blank form). The system synthesizes the prompt:
   • Clinical terminology for physicians and district teams.
   • Plain-language definitions for parents the first time a technical term appears (e.g. "lateralized", "MLU").
5. Review and refine:
   • Edit any section directly in the text editor.
   • Use the AI revision bar to adjust length, clarify clinical phrasing, or incorporate family interview notes.
6. Save and export:
   • Click Save to Paperwork. In the dialog, enter a descriptive title (e.g. Evaluation Report — Bryce C. (Oct 2026)) and click Save. The document attaches to the client's record immediately with zero page refresh required.
   • Click Export to download a formatted Microsoft Word (.docx) document or print-ready PDF.

Medicaid encounter logging & signaturesCopy Anchor Link

When completing daily encounter notes via the Session Logger:

• Draw your signature once in the Signature pad. The system records your first stroke with an immutable timestamp (signedAt).
• Supervising SLPs can add their license number and cosignature attestation.
• Exporting prints the real clinical signing date and embedded signature image—never the export timestamp.

TroubleshootingCopy Anchor Link

NextCopy Anchor Link

• Review progress: track goal mastery trajectories from session data.
• Write a SOAP note: complete daily session notes with acoustic analytics.