Medical Records

Each healthcare institution will have its own systems and procedures for maintaining clinical records. These will include standards for what minimum data must be (legally) included and reported on. It is of paramount importance that practitioners follow the guidance of their professional body, their employer and any other relevant governing body when compiling a written record of any clinical interventions or actions.

The case notes sheet provided here is just one (brief) template that gives suggestions for how practitioners might consider recording progress of clients attending the Strengthening the Speaking Voice course for adults with functional dysphonia.