Clinical Documentation Guidelines

Using SLP Mode

Gestallt’s SLP Mode provides structured fields for clinical documentation:

Developmental Stages (1-6)

Classify each gestalt according to the Natural Language Acquisition stages:

Stage	Classification Criteria
1	Whole, unmodified echolalia
2	Mixed/mitigated gestalts
3	Isolated single words or 2-word combinations
4	Novel, original phrases
5	Complex grammar structures
6	Flexible, spontaneous language

Feelings Classification

Document the emotional context:

• Happy — Joy, excitement, contentment
• Sad — Disappointment, grief, longing
• Angry — Frustration, protest, boundary-setting
• Neutral — Requests, comments, observations

Location Context

Where communication occurs matters:

• Car, Home, Outside, School, Store, Therapy, Other

Function

Classify the communicative function:

• Request, Protest, Comment, Greeting, etc.

Source Attribution

Document where gestalts originate:

• Media (specific show/movie), Person (family member), Script (book), Spontaneous

Collaborating with Families

Gestallt bridges clinical and home environments:

1. Review parent entries before sessions
2. Build on home observations in therapy
3. Share clinical insights in notes
4. Celebrate progress together

HIPAA Considerations

Gestallt is built with HIPAA-compatible infrastructure:

• Team-isolated data storage
• Role-based access controls
• Secure authentication
• No PHI in URLs

For organizations requiring a BAA, contact support.