How to Start the Year With Defensible Data Instead of a Documentation Mess

264
===

Marisha: [00:00:00] It's the beginning of the school year, and it feels like we've got ages before progress reports roll around, and it's easy to tell ourselves, "Oh, we'll figure this out later. We'll set up our data system or refine it later. We have time." But right now is the best time to get started instead of having to scramble and piece together progress notes from sticky notes and just pure vibes.

~Um, ~So today we're chatting about defensible data, and defensible data doesn't mean fancy. It just means consistent, usable data that helps us explain student progress clearly and in a way that can be understood by ourselves, by parents, administrators, advocates, potentially lawyers if they get involved, ~um, ~and also for the purposes of billing.

And we do not need to collect every possible data point and constantly have [00:01:00] our data binders out to have, quote-unquote, "defensible data". We need to be collecting the right kind of information consistently enough to support our decisions and to be able to document that students are making progress, and if they're not making progress, showing some of that clinical decision-making in how we are supporting students towards being able to make that progress.

So we should be able to answer four questions with our defensible data and documentation. ~So ~One, what were we targeting? Two, how did the student perform? Three, what level of support did they need? And four, what's the next step? What's our plan going forward? And this is a simple list of questions, and it hopefully helps reduce our anxiety because we don't need to have perfect documentation. We just need clear documentation.

And there's a really [00:02:00] easy way to make this happen. It doesn't have to be stressful or intense or difficult. ~Um, ~We just need a simple system that we can actually use.

The beginning of the school year is the perfect time to build that system and get all of our data on the same page, ~um, ~in a nice clean system, ~um, ~to make everything easier from progress notes, IEPs, if we ever get requests for our data or ~if there's... ~if there are advocates involved, having this data system set up from the beginning of the school year will make it so much easier and so much less stressful when things do come up. So we want to make sure that we have a place to keep track of our students' goals, the data for those goals, ~um, ~and have easy, quick session notes, ~um, ~and just a routine to help us take that data and to bill or process it in whatever way we need to.

~Um, ~And then we also need a way to flag [00:03:00] students who are meeting their goals or maybe who aren't making progress or who need closer monitoring, ~um, ~and our documentation is a great way to do that. So we wanna make sure that we're keeping it practical. We can't have a system that takes too long, that isn't feasible in our sessions.

One year, ~um, ~I really wanted to be able to take data for a group of students on one sheet of paper, but my district required individual data sheets, and ~I just, ~I hated having to flip between a bunch of different data sheets ~uh, ~during the session. So I ended up creating this sticker system where I had all of my students' goals on one page, and then I attached labels to it and wrote the data on the labels, and then I was supposed to transfer them to the individual data sheets. ~Let me tell you, ~I got so behind, and then I also had to do billing, and then at progress note time I was trying to catch up. It was just a mess. ~Um, ~So ~the, I think ~the system that makes it easy to take data [00:04:00] in groups but have them saved at the individual level, ~um, ~and just make this process as seamless as possible, I really think digital is the way to go, and I know that a lot of us are like, "I can't go digital, I'm too old school," ~or whatnot, ~but ~I ~I promise you that this is the most efficient way to take data, and, ~um, ~it's ~really, ~really simple and easy to get set up and then to actually do the documentation. You can easily take data.

~Um, ~You don't have to do any mental math. It calculates the accuracy for you. It automatically plugs it in, ~it, um, like into your... the data for-- It adds it to your student's goals, ~adds the data to your student's goals, and then it also automatically generates a note based on the information that you're plugging in.

~Um, ~And then you can take just a quick second to jot down any additional analysis. But it is so, so easy, and it makes it possible to get that defensible data [00:05:00] during a session within the session. And it's ~um, ~really time efficient, and you can get it all done within the session. So we have a digital data boot camp that walks you through exactly how to set up all of this.

~Um, and so it- ~If you go to slpnow.com/ddb, it stands for Digital Data Boot camp, so ddb. ~Uh, ~If you're wanting some handholding ~um, ~in getting this set up, ~uh, ~this is a great place to start and we just walk you through how to get everything set up. ~It'll make-- ~It'll automatically generate graphs for you.

You'll have all of your attendance logged, so if there's any questions, ~um, ~you can easily document ~like ~when students were absent or when sessions were missed ~to var- ~due to various reasons, which will be really important to be able to easily pull up if there's any legal questions or whatnot.

The goal behind collecting this data is to help ourselves [00:06:00] make clinical decisions. ~And We, in terms of what that looks like, the way that I've found ... ~And everyone can end up having a slightly different system, but I recommend creating a strategy for yourself, ~um, ~and then using that consistently and making sure that you're being consistent with your data collection.

~Um, so ~I'm just going to share what works for me, ~um, ~but you don't have to do it the exact same way. There's plenty of ways that you can set up your data collection that ~um, ~will meet all of the legal requirements and make your job easier. But I like to rotate through my goals. So every session, each student has a primary goal.

So if I have three students in the group, we might be targeting three different goals if they don't have any overlap. But I start the session, we review the students' goals, we pick our primary focus, and I grab a quick probe for one goal per student, and that gives me really clean data. It shows me ~what, ~where the student is at.

~Um, so ~Let's say I have a group of three students, ~just to make it easy to keep track of, let's say ~A, B, C. [00:07:00] A is working on producing K, B is working on naming items and categories, and then C is working on producing narratives, ~whatever it might be. ~So we run through a quick probe for each of those goals.

~So ~Student A will produce some K words if that's what the level that their goal is written at, then B ~will, ~will give them ~like ~a quick visual to, ~um, ~identify items and categories and then student C, for some of the goals, ~I might-- ~like producing a narrative that might make more sense just to do a rubric and collect that data in the context of the session.

~Um, ~So like I said, we can be flexible, but depending on the goal, I will grab a quick probe or use a rubric to collect data in context, and the goal would be written that way if it's that type of goal. ~But I-- ~By seeing where the students are at without any support, ~um, ~I'm able to document that accuracy, so that gives me some of that defensible data.

And then that lets [00:08:00] me know what the student needs. And so I can document, okay, because they were at zero percent accuracy, we spent the majority of the session focusing on teaching, and that's showing that I'm meeting the student where they're at. ~Where-- ~However, if they're at seventy percent accuracy, they're nearing mastery, and I want to give them the opportunity to practice that in context.

So getting that initial probe data is really helpful for me, and then I'm able to document that I'm using that data for my clinical decision-making. And if you're using SLP Now for your data collection, you can easily see students' graphs, ~um, ~and it makes a trend line. If their baseline is zero percent accuracy and you want them to be at eighty percent by the end of the school year, ~um, ~there's a trend line that shows where we would expect students to be at any point in the school year.

And of course, skills don't always follow this l-linear trajectory. But if I keep seeing a student at zero, zero, zero, zero, zero, zero for [00:09:00] months on end, that tells me that I need to try a different strategy or I didn't write a good goal and I need to adjust the goal. ~Um, ~Having access to that data makes it really easy to make those decisions.

So going back to the main point, I like to start with a quick probe at the beginning of the session, and then that informs how we approach the rest of the session. And then if the session is primarily focused on teaching, I might document the level of support that the student needed ~um, ~in very structured kind of teaching activities.

Or if they are at a higher accuracy and we're doing a more contextualized activity, I would still document the level of support. And in SLP Now, we have a dropdown menu with ~some kind of ~predefined levels of support, but you can add in your own things to that dropdown so you're not having to type out the same things over and over ~and over.~

~Um, ~You can customize what's in that menu, and then [00:10:00] you just click for the description that works best for your student. ~Um, ~So that is a great way to document that level of support as well. You can easily see the past levels of support too, so that if you can't remember, ~oh, darn, ~what worked well for this student last time, you can quickly reference that and use that in future sessions as well.

So you're having that defensible data, but it also makes your job easier and helps you better support the student. ~Um,~

And then, ~um, ~I didn't address this in a lot of detail, but I mentioned that I like to do a quick probe at the beginning of the session, and these are super short, usually about five questions.

In SLP Now, if you use our goal bank, we have probes attached to every single goal, so you don't have to create any or have a system to keep track of them. They're all linked in your sessions to your student's goals. So you just click ~to take data on, like ~to take [00:11:00] probe data. It launches the stimulus items, and then you just click plus, minus, plus, minus, and that's your probe data.

And we like to use the same probe over time. ~I end up, if they ... ~Most students have a handful of goals, ~um, ~and then we end up ~targeting each goal about, ~formally targeting each goal about once a month. So I have a data point for each goal about once a month. ~Um- ~But then I use the same probe as a way to measure progress, and I'm not using the probe items in treatment.

They're just different stimulus items than we are using in treatment, so it is an opportunity to measure generalization. ~Um, ~So that's what that looks like. ~Um, ~The probe data is really nice because then we know exactly how students are responding and exactly what they've been given.

So if there's ever a legal question or an advocate is involved, you can show your probe as needed and give [00:12:00] context of like, okay, this is what they were expected to do. ~Um, ~Instead of just having sticky notes with tally marks and trying to figure out what that means, ~um, 'cause yeah. ~So we know that we're having high quality, consistent data.

The goal is not to have more data. We just want data that is faster, consistent, and easy to stand behind. And ~every note that you write now, like ~every note that you write now, every piece of data that you plug in is helping your future self. ~Um, ~Any data point that you enter into SLP Now can be used to generate billing notes, to generate progress notes automatically, to help build your present levels.

~And alternatively, it, ~If we are collecting our data in a different way, it can be creating a scavenger hunt for ourselves. ~Um, ~So what do you want your Medicaid billing and your progress notes and your present levels to look like? Do you want to have to be ~s- ~going on a scavenger hunt looking for the pieces of data, or do you want a system that automatically pulls them [00:13:00] together for you and helps you automatically write those billing notes, progress notes, present levels?

~All of that. Um, and ~Automatically pulling trends, summarizing growth, generating clear Medicaid summaries without having to write everything from ~stra- ~scratch. Being able to share graphs with parents and administrators, advocates. ~Um, ~to document the progress that a student is making, why goals are changing, why we should continue services, why a student is ready to exit.

Having that clear data makes all of those decisions way easier.

And what this looks like in practice, ~um, ~I start my session with a quick probe, and then I focus on being the best therapist that I can be for the remainder of the session. And then as we're closing out the session, I ~um, ~document the level of support that I provided. I click the button to generate the session note, and then I [00:14:00] will plug in any additional details of anything that I think is relevant that came up during the session and what I want to do next.

And if the student is absent, I can document that in the session, and I can document the reason, and then SLP Now will automatically generate a attendance chart.

So if there are any questions about, "Okay, why did you miss this number of sessions?" Then I can say, "Okay. Well, they were on a field trip this time. The student was out sick this time." You have all of that data ready to go. ~And yeah. So, um,~

When we have that type of system, we, again, get to have way easier Medicaid billing, progress notes.

Like Janelle said, "I fly through progress notes. I'm notoriously the first one done, and I have way more students than any of the other special education teachers, and I always know that I'm in a solid place because all I [00:15:00] have to do is use my laptop. I don't have to lug a bazillion binders around."

So that's what a good system does. It turns billing and progress notes and writing IEPs from a crisis into a fun, pleasant, exciting review. We get to see our students making progress, and we get to celebrate that in this documentation, and it gets to be a really fun thing versus something that we dread.

So in terms of practical takeaways for this episode, Here's a couple things that you might try. One, create a repeatable probe for a goal that you target all of the time. ~Um, ~Find a simple way to document your cueing or support level. ~Um, ~We have a Level of Support Rubric that might be helpful.

I'll add that in the show notes, ~um, ~a link to the level of support rubric as [00:16:00] well. ~Um, ~If you Google SLP Now level of support rubric, you can find that there too. ~Um-~

And then a third suggestion is thinking about a routine that you can use in your sessions and at the end of the day to make data collection easier.

You don't have to overhaul everything. Just make sure that you are thinking ahead and try setting up a system so that future you isn't stuck going on a scavenger hunt trying to decode ~um, ~a pile of sticky notes.

I hope that this episode helps make documentation and defensible data feel a little bit lighter and a little bit easier. You've got this. You're an amazing SLP, and I really hope this helps.