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speech and voice therapy clinical documentation assessment treatment
Head and Neck Cancer Survivorship Care
Page 21
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Head and Neck Cancer Survivorship Care
Page 21
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Below is a comprehensive clinic file framework for a Speech and Voice Therapy service. This covers everything typically included in a clinical file, from intake through discharge.
🗂️ Clinic File: Speech and Voice Therapy
1. Patient Identification & Referral
| Field | Details |
|---|---|
| Patient name | |
| Date of birth / Age | |
| Gender | |
| Contact information | |
| Referring physician | (ENT, neurologist, oncologist, GP) |
| Reason for referral | |
| Date of referral / intake | |
| Insurance / funding |
2. Chief Complaint & History
- Primary complaint: hoarseness, voice loss, pitch changes, vocal fatigue, dysarthria, stuttering, aphonia, resonance disturbance, etc.
- Onset: sudden vs. gradual
- Duration and progression: stable, improving, worsening
- Aggravating/relieving factors: voice use, hydration, posture, rest
- Impact on daily life: professional voice use (teachers, singers, clergy), social participation, quality of life (QoL)
3. Medical & Surgical History
- Previous throat/laryngeal surgeries (laryngectomy, thyroidectomy, vocal cord surgery)
- Head and neck cancer (HNC) treatment — radiation, chemotherapy, surgery
- Neurological conditions: Parkinson's disease, stroke, ALS, MS, cranial nerve palsy (CN X → dysphonia; CN XII → dysarthria)
- GERD/LPR (laryngopharyngeal reflux)
- Respiratory conditions (asthma, COPD)
- Medications affecting voice (ACE inhibitors, antihistamines, steroids)
- Psychiatric/psychological history relevant to psychogenic dysphonia
4. Vocal Habits & Lifestyle
- Occupation and vocal demands
- Tobacco / alcohol use
- Hydration habits
- Vocal hygiene practices (shouting, throat clearing, whispering)
- Singing or performance activities
5. Assessment Protocol
5.1 Perceptual Voice Evaluation
- GRBAS Scale: Grade, Roughness, Breathiness, Asthenia, Strain (0–3 each)
- CAPE-V (Consensus Auditory-Perceptual Evaluation of Voice): overall severity, roughness, breathiness, strain, pitch, loudness
5.2 Acoustic Analysis
| Parameter | Normal Range |
|---|---|
| Fundamental frequency (F0) | M: 85–180 Hz / F: 165–255 Hz |
| Jitter (%) | < 1.04% |
| Shimmer (%) | < 3.81% |
| Noise-to-Harmonics Ratio (NHR) | < 0.19 |
| Maximum Phonation Time (MPT) | ≥ 15 seconds |
5.3 Aerodynamic Measures
- Subglottal air pressure
- Glottal airflow rate
- Phonation threshold pressure
5.4 Patient-Reported Outcome Measures
- Voice Handicap Index (VHI-10): functional, physical, emotional subscales
- Voice-Related QoL (V-RQOL)
- Reflux Symptom Index (RSI) where LPR is suspected
5.5 Laryngoscopy / Videostroboscopy Findings (from ENT)
- Vocal fold mobility, mucosal wave, closure pattern, lesions (nodules, polyps, cysts, granulomas)
- Paralysis / paresis
- Post-laryngectomy anatomy
5.6 Speech & Resonance Evaluation
- Articulation assessment
- Resonance (hypo/hypernasality)
- Fluency
- Intelligibility rating
6. Diagnosis / Clinical Impression
Voice disorders may include:
- Functional dysphonia (muscle tension dysphonia - MTD)
- Organic dysphonia (vocal fold nodules, polyps, cysts, paralysis, sulcus vocalis)
- Neurogenic dysphonia (spasmodic dysphonia, vocal tremor, Parkinson's hypokinetic dysarthria)
- Psychogenic/conversion dysphonia/aphonia
- Post-laryngectomy voice (alaryngeal speech)
- Radiation-associated voice deterioration (per HNC Survivorship guidelines)
7. Treatment Plan
Goals (Short-Term / Long-Term)
- Improve vocal quality, pitch control, loudness, endurance
- Restore functional communication
- Optimize QoL and return to occupational/social demands
Therapy Approaches
| Approach | Indication |
|---|---|
| Vocal hygiene counseling | All voice disorders |
| Resonant voice therapy (e.g., Lessac-Madsen) | Functional dysphonia, nodules |
| Lee Silverman Voice Treatment (LSVT LOUD) | Parkinson's disease / hypokinetic dysarthria |
| Manual circumlaryngeal therapy | Muscle tension dysphonia |
| Confidential voice / voice rest protocol | Acute laryngitis, post-surgical |
| Semi-occluded vocal tract exercises (SOVTE) | Nodules, polyps, functional dysphonia |
| Electrolarynx / tracheoesophageal voice training | Post-total laryngectomy |
| Prosthetic management (TEP) | Post-laryngectomy — managed by SLP |
| Behavioral articulation/resonance therapy | Palatal defects, glossectomy |
| Botulinum toxin support therapy | Spasmodic dysphonia (adjunct to ENT injection) |
According to Head and Neck Cancer Survivorship Care guidelines (p. 21): HNC survivors with communication disorders should be referred to a speech-language pathologist for assessment and management, with early assessment and intervention preferred (Level IA–IIA evidence).
8. Session Progress Notes (SOAP Format)
S – Subjective: patient-reported symptoms, vocal effort, fatigue
O – Objective: acoustic/perceptual findings, exercises completed, compliance
A – Assessment: progress toward goals, barriers
P – Plan: next session targets, home practice, onward referral if needed
O – Objective: acoustic/perceptual findings, exercises completed, compliance
A – Assessment: progress toward goals, barriers
P – Plan: next session targets, home practice, onward referral if needed
9. Multidisciplinary Coordination
- ENT / Laryngologist: laryngoscopy, surgical intervention, botox injections
- Oncology team: for HNC-related voice/speech changes
- Neurologist: for neurogenic voice/speech disorders
- Maxillofacial prosthodontist: palatal obturators, palatal drop prostheses for resonance/articulation
- Psychologist/Psychiatrist: psychogenic dysphonia, conversion disorders
- Dietitian/GI: LPR/GERD management
10. Discharge Criteria & Summary
- Functional communication goals achieved
- Patient demonstrates independent vocal hygiene and home exercise program
- VHI-10 / V-RQOL scores at or near normal
- MPT ≥ 15 seconds (or at functional level for patient's demands)
- Discharge summary includes: diagnosis, interventions provided, outcomes, onward recommendations
11. Red Flags Requiring Urgent ENT Referral
- New or rapidly progressive hoarseness > 3 weeks in an adult (especially smoker/HNC history)
- Stridor or respiratory compromise
- Hemoptysis
- Dysphagia with weight loss
- Suspected new or recurrent malignancy (per HNC Survivorship Care, p. 21 — new progressive hoarseness/dysarthria can indicate new cancer and should be evaluated first by the HN surgeon)
This framework covers the complete lifecycle of a speech and voice therapy clinical file. Let me know if you need a specific section expanded — for example, a pediatric voice file, a post-laryngectomy file, or a neurogenic dysarthria file.
speech and voice therapy services content for our clinic file
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speech voice therapy services clinical protocols assessment tools
Head and Neck Cancer Survivorship Care
Page 21
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voice disorders dysphonia dysarthria fluency resonance therapy interventions
Wilson’s Disease
Page 21
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Here is a fully structured Speech and Voice Therapy Services section ready for your clinic file:
Speech and Voice Therapy Services
1. Service Overview
The Speech and Voice Therapy service provides comprehensive assessment, diagnosis, and treatment of communication disorders affecting speech production, voice quality, resonance, fluency, and functional intelligibility. Services are delivered by qualified Speech-Language Pathologists (SLPs) and are coordinated with ENT, neurology, oncology, and other relevant specialties.
2. Populations Served
- Adults and children with voice disorders
- Post-surgical patients (laryngectomy, thyroidectomy, airway surgery)
- Head and neck cancer (HNC) survivors
- Neurological conditions (Parkinson's disease, stroke, ALS, MS, traumatic brain injury)
- Patients with structural anomalies (cleft palate, palatal defects, glossectomy)
- Professional voice users (teachers, singers, clergy, broadcasters)
- Patients with psychogenic or functional voice disorders
- Patients with laryngopharyngeal reflux (LPR) affecting voice
3. Referral Criteria
Patients may be referred by any clinician for the following:
| Indication | Examples |
|---|---|
| Voice quality changes | Hoarseness, breathiness, roughness, strain |
| Pitch or loudness disturbances | Pitch breaks, reduced loudness, monotone |
| Vocal fatigue | Voice tires with use, worsens across the day |
| Aphonia | Complete loss of voice |
| Resonance disorders | Hypernasality, hyponasality |
| Dysarthria | Slurred, reduced intelligibility speech |
| Fluency disorders | Stuttering, cluttering |
| Post-surgical voice rehabilitation | Post-laryngectomy, post-thyroplasty |
| HNC-related communication disorders | Radiation-associated speech/voice changes |
⚠️ Urgent ENT referral first for: new or progressive hoarseness >3 weeks, stridor, hemoptysis, dysphagia with weight loss, or suspected malignancy — before SLP intake.
4. Assessment Services
4.1 Perceptual Voice Assessment
- GRBAS Scale: Grade, Roughness, Breathiness, Asthenia, Strain (rated 0–3)
- CAPE-V (Consensus Auditory-Perceptual Evaluation of Voice): overall severity, roughness, breathiness, strain, pitch deviation, loudness deviation
4.2 Acoustic & Aerodynamic Analysis
| Measure | Clinical Significance |
|---|---|
| Fundamental frequency (F0) | Pitch disorders, gender-affirming voice |
| Jitter & Shimmer | Vocal fold irregularity, organic pathology |
| Noise-to-Harmonics Ratio (NHR) | Breathiness, turbulent airflow |
| Maximum Phonation Time (MPT) | Breath support, glottic closure efficiency |
| Subglottal pressure / airflow | Phonatory effort, aerodynamic efficiency |
4.3 Patient-Reported Outcome Measures (PROMs)
- Voice Handicap Index (VHI / VHI-10): functional, physical, emotional impact
- Voice-Related Quality of Life (V-RQOL)
- Reflux Symptom Index (RSI): LPR screening
- Stuttering Severity Instrument (SSI-4): for fluency disorders
4.4 Speech & Communication Assessment
- Articulation and phonological assessment
- Resonance and nasality evaluation
- Intelligibility rating (conversational and structured)
- Dysarthria profiling (type and severity)
- Oro-motor function screening
4.5 Laryngoscopy Liaison
SLPs review and document findings from ENT/laryngologist videostroboscopy reports including:
- Vocal fold mobility and symmetry
- Mucosal wave quality
- Glottic closure pattern
- Presence of lesions (nodules, polyps, cysts, granuloma, Reinke's edema)
- Post-laryngectomy anatomy
5. Treatment Services
5.1 Voice Therapy
| Therapy Program | Target Condition |
|---|---|
| Vocal hygiene counseling & education | All voice disorders — first-line |
| Resonant voice therapy (Lessac-Madsen) | Functional dysphonia, vocal nodules |
| Semi-occluded vocal tract exercises (SOVTE) | Nodules, polyps, functional dysphonia, post-surgical |
| Manual circumlaryngeal therapy | Muscle tension dysphonia (MTD) |
| Confidential voice protocol | Acute laryngitis, vocal fold haemorrhage, early post-op |
| Accent Method | Functional and neurogenic dysphonia |
| Flow phonation techniques | Hyperfunction, MTD |
| Pitch and loudness shaping | Parkinson's, neurogenic disorders, gender-affirming voice |
5.2 Lee Silverman Voice Treatment (LSVT LOUD)
A standardised, intensive voice treatment for Parkinson's disease and other hypokinetic dysarthrias. Delivered over 16 sessions across 4 weeks. Targets loudness as the primary driver of improved articulation, prosody, and intelligibility. Evidence base: multiple Level I RCTs.
5.3 Dysarthria Rehabilitation
Speech rehabilitation is tailored to dysarthria type (Wilson's Disease Guidelines, p. 21):
| Dysarthria Type | Therapy Focus |
|---|---|
| Spastic | Relaxation techniques, reducing effort |
| Ataxic | Rate modification, prosody training |
| Hypokinetic (Parkinson's) | LSVT LOUD, loudness and articulation |
| Flaccid | Compensatory strategies, prosthetic options |
| Mixed | Combined approaches per dominant features |
5.4 Alaryngeal Voice Rehabilitation (Post-Laryngectomy)
- Tracheoesophageal prosthesis (TEP) training: management of the valved voice prosthesis, optimising intelligibility and QoL (Level IA–IIA evidence per HNC Survivorship Care, p. 21)
- Electrolarynx training: device selection, placement, speech naturalness
- Oesophageal voice training: where appropriate
5.5 Prosthetic & Structural Rehabilitation
- Palatal obturator fitting support: in coordination with maxillofacial prosthodontists for palatal defects — improves speech resonance
- Palatal drop prosthesis support: improves articulation after subtotal or total glossectomy
- Tracheostomy speaking valve (Passy-Muir) fitting and training
5.6 Fluency Therapy
- Stuttering modification therapy (desensitisation, cancellations, pull-outs)
- Fluency shaping techniques (smooth speech, prolonged speech)
- Cluttering management (rate and awareness training)
- Psychosocial support integration
5.7 Resonance Therapy
- Nasal resonance training (hypo/hypernasality)
- Velopharyngeal dysfunction (VPD) management in collaboration with surgical team
- Gender-affirming resonance modification
5.8 Vocal Hygiene & Education Program
All patients receive a personalised vocal hygiene plan including:
- Hydration targets (systemic and mucosal)
- Voice rest guidance
- Elimination of vocal abuse (shouting, excessive throat clearing, whispering)
- Environmental modifications (humidity, allergen reduction)
- Reflux management advice (in coordination with GI/ENT)
6. Multidisciplinary Team (MDT) Links
| Specialty | Role in Voice/Speech Care |
|---|---|
| ENT / Laryngologist | Laryngoscopy, surgical intervention, botulinum toxin injection |
| Neurology | Neurogenic voice/speech disorders, tremor, Parkinson's |
| Oncology / Radiation Oncology | HNC-related communication disorders |
| Maxillofacial Prosthodontics | Palatal obturators, palatal drop prostheses |
| Gastroenterology | LPR/GERD management affecting voice |
| Psychology / Psychiatry | Psychogenic dysphonia, conversion aphonia, anxiety in stuttering |
| Dietitian | Post-laryngectomy, dysphagia overlap, nutritional support |
| Audiology | Hearing loss impact on voice and speech monitoring |
7. Session Structure & Frequency
| Phase | Frequency | Duration |
|---|---|---|
| Initial assessment | Single extended session | 60–90 minutes |
| Active therapy (standard) | Weekly or twice weekly | 45–60 minutes |
| LSVT LOUD (intensive) | 4 sessions/week × 4 weeks | 60 minutes |
| Maintenance / review | Monthly or as needed | 30–45 minutes |
| Discharge review | Single session | 45–60 minutes |
8. Outcome Monitoring
Progress is reviewed at regular intervals using:
- Repeat acoustic/perceptual measures (GRBAS, CAPE-V, MPT)
- PROMs (VHI-10, V-RQOL) at intake, mid-point, and discharge
- Goal attainment scaling (GAS)
- Intelligibility ratings (pre/post)
- MDT review for complex cases
9. Discharge Criteria
Discharge is considered when:
- Functional communication goals are achieved
- PROMs reach clinically significant improvement (e.g. VHI-10 ≤ 11)
- MPT ≥ 15 seconds or at functional level for the patient's vocational demands
- Patient demonstrates independent home exercise program and vocal hygiene adherence
- No further benefit anticipated from continued therapy
- A written discharge summary is provided to the referrer with outcomes and ongoing recommendations
10. Documentation Standards
Each clinical file includes:
- Referral and intake form
- Case history and medical background
- Assessment findings (perceptual, acoustic, PROM scores)
- Videostroboscopy/laryngoscopy report liaison
- Individualised treatment plan with short- and long-term goals
- SOAP-format session progress notes
- MDT correspondence
- Home exercise program (HEP) records
- Discharge summary
Let me know if you would like this adapted for a specific sub-specialty (e.g. paediatric voice, gender-affirming voice, neuro-rehabilitation unit) or formatted as a printable clinic document.
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