Speech pathology report template (free, with guidance)

A good paediatric speech pathology assessment report has nine sections: identifying details; reason for referral; background and case history; assessment methods; results; clinical impressions; recommendations; goals or next steps; and sign-off. The template follows and is free to copy into your own system. Adapt the headings to your service and funders. The guidance after the template explains what to put in each section and how to write so that parents, teachers, doctors and NDIS planners can all use the same document.

This is one workable structure drawn from common clinical practice. Speech Pathology Australia (SPA) does not publish it or prescribe it.

What sections should a speech pathology report include?

Copy the block below and replace each bracketed prompt with your own content.

SPEECH PATHOLOGY ASSESSMENT REPORT

Summary for the family

[Three to five plain sentences: why the child was seen, what you found, what you recommend and what happens next. No jargon. Write this last.]

1. Identifying details

[Child's name, date of birth, age at assessment, parent or guardian, referrer, date(s) of assessment, clinician name and credentials.]

2. Reason for referral

[Who referred and why, in the words of the referrer and family. State the family's own concerns and goals for the assessment.]

3. Background and case history

[Relevant developmental, medical, hearing, educational and family language history. Languages spoken at home and at school. Previous therapy. Mark what is parent-reported and what is from records.]

4. Assessment methods

[List each formal test (name, edition, date administered), each informal measure (language sample, observation, parent or teacher questionnaire), the setting, who was present, and any interpreter used. Note any change from standard administration.]

5. Results

[Report observations and scores separately. For each test: scores reported as the manual provides them, which norms were used, and a plain description of what the child did.]

6. Clinical impressions

[Your interpretation. Say what the results mean for communication in daily life, name the diagnostic framework or terminology you used, and state how confident you are and what remains unclear.]

7. Recommendations

[Specific: what service, how often, in what setting, delivered by whom, for how long, and when it will be reviewed. Include referrals to other professionals and strategies for home and school.]

8. Goals or next steps

[Two to four functional goals agreed with the family, written so progress can be measured at review.]

9. Sign-off

[Consent to share and who the report may go to. Name, credentials, CPSP status if held, signature, date of report.]

Who is reading your report?

Most paediatric reports have more than one reader. A parent wants to know what the findings mean for their child. A teacher wants to know what to do in the classroom. A GP or paediatrician wants the clinical picture and any referral needs. An NDIA planner wants evidence about function and support needs.

You cannot write a separate report for each, so layer one: a plain-language summary for the family at the top or in a box, a clinically precise body, and recommendations with short sub-headings for home, school and other professionals.

How do you write the assessment methods and results?

The methods section is what lets another clinician judge your findings. For each standardised test, record:

• the test name and edition
• the date it was administered
• the scores as the manual provides them, such as standard scores and percentile ranks, with confidence intervals where the manual gives them
• which norms were used
• any deviation from standard administration

Deviations matter. If an interpreter was used, or the child was tested in a second language, say so and say how that limits interpretation. A reader who sees only a score will assume a standard administration.

Do not treat any score as self-explanatory. State what the test measures, how the child performed relative to the norm group, and what that means functionally. Avoid describing any particular score as typical without naming the test and the norms you are comparing against.

Informal assessment deserves the same care. Record how a language sample or observation was collected, in what context, and how long it ran. Then keep observation and interpretation apart. "Child A produced mostly single words and two-word phrases during a 15-minute play sample" is an observation. "This suggests an expressive language difficulty" is an interpretation, and belongs in the clinical impressions section.

How do you write clinical impressions?

Many readers turn to this section first, so give it the most care. State what you think is going on, how the results support it, and what is uncertain. Use current terminology and name the diagnostic framework you used, so readers know what your label means. Many clinicians use the CATALISE consensus terminology (Bishop and colleagues, 2017) for developmental language disorder, and if you do, say so in the report.

If the evidence is not enough for a diagnosis, say that plainly and describe what further information would settle it. A report that records "emerging concern, review after a block of therapy" is more useful than a label the evidence cannot carry.

How do you write recommendations?

A recommendation is useful when someone else can act on it without phoning you. Include:

• what service is recommended and the approach, if relevant
• how often and for how long each session runs
• the setting (clinic, school, home, telehealth) and who delivers it
• the duration of the block and the point at which you will review
• who else is involved, such as a teacher, aide or other health professional

Stay within your scope of practice. If you see a need for hearing assessment, a paediatric review or psychology input, recommend a referral and say why, without speaking to the other discipline's conclusions. Link recommendations to the goals the family has set.

Worked example: a short report summary

The following is a fictional child, with placeholders where results would go. It shows the shape of a summary, not a result.

Summary for the familyChild A, 5 years 4 months, was referred by their GP because of concerns about how they put words together. Child A was seen on [date] at [setting] with a parent present. We tested language using [test name and edition], listened to Child A during play, and asked a parent to complete [questionnaire]. >ResultsOn [test name and edition], Child A's expressive language score was [standard score] ([percentile] percentile rank), using [norms]. In a play sample, Child A used [description of utterance length and structures]. Understanding of spoken language was [description]. >Clinical impressionsResults are consistent with [impression], using [diagnostic framework]. Child A's difficulty affects [functional impact, for example joining in at preschool]. >Recommendations[Service] for [frequency] sessions of [length] at [setting], delivered by [who], for [duration], with review in [period]. Strategies for home and preschool are attached. Referral to [other professional] is recommended because [reason].

Common mistakes in speech pathology reports

• Jargon without explanation. Terms such as "phonological processes" or "receptive-expressive gap" are fine for colleagues. Explain them in a short phrase for everyone else.
• Results without interpretation. A table of scores tells the reader nothing about the child's daily communication. Say what the scores mean.
• Vague recommendations. "Ongoing speech therapy" gives no frequency, setting, duration or review point.
• Copying forward from a previous report without updating. Old history, old goals and old wording can sit in a new report unnoticed. Reread every line against the current assessment.
• Missing consent and sharing details. Record who consented, who the report may be shared with, and the date.

Writing for NDIS and school audiences

NDIS and school readers need the same assessment with a different emphasis. The NDIA's guidance on report writing asks for functional capacity linked to the participant's goals, with evidence about the supports recommended and why. Its plan reassessment guidance suggests asking whether recommended supports are within your scope of practice and how they link to therapy outcomes and goals. For the full list of what the NDIA looks for, see our article on what an NDIS progress report should include. Check the current NDIS pages before you submit, because the NDIS website notes that it is being updated for new legislation.

For schools, lead with what the teacher can do, in plain words, and share only with the family's consent.

Professional standards to keep in mind

This is general information, not legal advice. Speech pathology is self-regulated through SPA and Certified Practising Speech Pathologist (CPSP) status. It is not part of the Ahpra registration scheme. Two SPA documents shape report writing: the Code of ethics (2020) and the Professional standards for speech pathologists in Australia (2020).

Records retention rules differ between states and territories. As one example, NSW private health service providers keep health information for 7 years from the last service for adults, and for a child until they turn 25 (HRIP Act s 25, per the NSW Information and Privacy Commission). Check your own state or territory law and your professional body.

If AI drafts any part of a report, SPA's May 2024 position statement on artificial intelligence in speech pathology says AI-generated information needs detailed critique by the speech pathologist for currency, accuracy and relevance. The clinician reviews the whole draft and signs it.

In short

• A paediatric speech pathology report has nine sections, from identifying details to sign-off, with a plain-language summary for the family on top.
• Name every test, edition, date, norms and deviation from standard administration, and interpret each result.
• Keep observation and interpretation in separate places, and name the framework behind any diagnostic label.
• Make recommendations specific: frequency, setting, who, duration and review point.
• Write for the several people who will read it, and record consent to share.

FAQ

What should a speech pathology assessment report include?

A paediatric report usually includes identifying details, reason for referral, background and case history, assessment methods, results, clinical impressions, recommendations, goals or next steps, and a signed sign-off. A short plain-language summary for the family helps non-clinical readers.

Is there a required format for a speech pathology report in Australia?

We have not found an SPA-mandated report format, so services and funders set their own expectations. Use a consistent structure, follow the SPA Code of ethics and Professional standards, and check what any funder asks for before you write.

How do you report standardised test results in a speech pathology report?

Name the test and edition, the date administered and the norms used. Give scores as the manual provides them, including confidence intervals where available, note any deviation from standard administration, and say what the results mean for the child's communication.

How long should I keep a child's speech pathology report?

It depends on your state or territory. In NSW, private health service providers keep health information for 7 years from the last service for adults, and until a child turns 25 if the information was collected under 18. Check your own jurisdiction's law and your professional body.

Syntropic Health drafts reports inside the case, from the notes and results already recorded there, and the clinician reviews, edits and signs every one.

Sources

• speechpathologyaustralia.org.au
• speechpathologyaustralia.org.au
• ndis.gov.au
• ndis.gov.au
• ipc.nsw.gov.au
• doi.org