Pediatric SOAP Note Examples for SLPs
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SLPs regularly use SOAP notes to record their clients’ progress after a session. While the SOAP note structure follows the same format, the content included in each section can vary for a number of reasons. We’ve created these SOAP note examples as a guide to help SLPs that work with a pediatric caseload.
SOAP note example for school-age child stuttering session
Subjective: The client was on time for their telehealth session. They said, “Can we play ‘memory’ today? Also, can we role-play telling people about my stuttering?”
Objective: During play, the client independently shared four communication situations when they thought self-disclosure could be helpful for reducing discomfort related to stuttering. Different scenarios were role-played such as disclosing to best friend, band teacher, general studies teacher, and school counselor. The client suggested they practice pseudo-stuttering to approximate what these situations might actually look and sound like. We brainstormed how it might feel before, during, and after self-disclosure and options for managing emotions.
Assessment: The client shared more communication situations than previously and spoke with confidence about their plan. Role-playing is a favorite activity and client is demonstrating less fear about what other people might think. The client is becoming more self-empowered and less bothered by stuttering moments. Their independent use of pseudo-stuttering was new and demonstrates increased comfort and confidence.
Plan: The client will attempt one self-disclosure conversation and report back during the next session. Continue with the plan of care and increasing the client’s confidence and comfort around stuttering.
SOAP note example for preschool articulation session
Subjective: The client joined the 1:1 in-person session at the client’s preschool after circle time was finished. They ran over to me and announced, “My bunny!” while holding out a stuffed animal. Client appeared proud and happy to share the bunny and include it in the session.
Objective: Session focused on generalization of voiceless back velar /k/ in word initial position with carrier phrases. “My bunny can ____,” “My bunny has a ____” with /k/ word initial words: kick, camp, catch, cap, cat, cow, etc. The client demonstrated each action with the bunny or laid the articulation cards on the bunny.
- 70% (14/20) of opportunities the client produced the /k/ sound in the phrases accurately when given a gestural cue (tapping at the back of the throat to encourage a back position of the tongue).
- 30% (6/20) of opportunities the client produced the sound without any cues.
Continued to target /k/ word initial in phases while playing picnic. Carrier phrase was “Can I have a ____?” Initially, client produced /t/ →/k/ and benefited from a model and gestural cue. Once a model was given, client produced /k/ at the beginning of the request without a model 80% (8/10) of opportunities.
Assessment: The client self-monitored for the first time with carrier phrases. The practice with gestural cues and the repetition helped them achieve this. The client is very motivated to use the bunny stuffed animal to demonstrate actions or possessions. After a model was given in the second activity, the client demonstrated that in structured activities they can maintain the new production with back tongue placement.
Plan: Continue with the plan of care. Send a list of words with /k/ word initial to the client’s mother and describe how to incorporate the use of carrier phrases at home during play. Introduce visual cues to to assist with generalization and maintenance and reduce reliance on phonemic cues.
SOAP note example for a session with a preschool language session
Subjective: Arrived for home session and client was between the couch and the front window. The mother of the client opened the door and said, “I’ve tried to coax him out, but he insists on staying behind the couch.” Mother of the client also said that the speech generating device was charging.
Objective: Continuing to build rapport and model and provide coaching to client’s mother around sensory processing and gestalts. Began by playing with trains in sight of client, but quietly. Encouraged the mother of the client to also sit on the floor and play with trains. Slowly started to add language and crash the toys. “Let’s crash! Ready…set…go!” Placed the train between the wall and couch. Continued playing crash with mother of client. Client grabbed the train and started to say, “Ready…set…go!” from behind the couch. Modeled, “this is fun,” “let’s play together,” “my train is blue,” “it goes fast, “make a big crash,” “make a small crash.” Client crawled out from behind the couch and crashed his train into his mother’s. Afterwards, his mother said, “Ready?” He said, “Set go!” and they crashed. Play continued and the client said “do it again,” “big crash,” “no crash.” At the end of the session, I made a plan with the client’s mother to charge the speech generating device at night and make it accessible during the day.
Assessment: Mother of client is building her confidence around getting into play and creating communication temptations. Client is demonstrating Stage 1 Gestalts and starting to produce Stage 2. He benefits from watching play first and then joining in.
Plan: Continue with a plan of care and brainstorm with client’s mother about other activities of interest and gestalts we can model. Check in about the new charging plan for the speech generating device.
SOAP note example for a session with a school-age language session, including executive function
Subjective: Client arrived on time for our telehealth session and said, “I’m so excited, I got a B on my animal report!”
Objective: Therapist used reflexive listening to increase client’s awareness of his process and to train his inner coach voice. Therapist asked, “How did you do that?” Client shared that he set aside time at home to write his report, used a timer for breaks, and played quiet music without words. These were all part of the plan he created in the previous session. Focused on self evaluation and asked the following questions: What helped you be successful? Having a plan. What was challenging? Getting started every day and staying focused when I wanted to play video games or go outside. What would you do differently next time? I’ll start my report earlier so I can take more breaks.
Client shared that he has a group project he’s worried about because he knows he gets distracted when there are more people involved in work. Talked about visualizing what it would look like to stay focused in the midst of others. What strategies could he use to help himself stay on task and interact with his group? He said he’d think about it and report back. Asked, What will help you remember? He answered, writing it in my notebook. He took out his notebook and wrote down: Strategies for working in the group, share next week.
Assessment: Client reported back about how he generated, initiated, and executed a plan to complete an undesirable task. Session’s focus was on self evaluation and finding the keys for replication. Client demonstrated self evaluation skills, including analysis, planning, and self-monitoring. He is making progress and moving toward greater independence.
Plan: Continue with the plan of care and check in with the client about his plan for group work.
SOAP note example for a pediatric voice session
Subjective: The client arrived to the session 10-minutes late with her Dad. She reported, “I no longer feel like I have to push so hard to talk.”
Objective: Therapist introduced resonant voice techniques to target optimal voice production with the client. Client created functional phrases from school with focus on /wh/ to produce a resonant voice , “What’s the homework due later today, Where’s the bathroom pass, When’s lunch?”. Client produced functional phrases with resonant voice in 8/10 opportunities with moderate visual cues.
Assessment: The client benefitted from visual cues to produce optimal voicing, rather than tactile or written cues. In this session, the client improved on producing optimal voicing in 8/10 opportunities. The previous two sessions the client required maximal visual and written cues to improve voice production.
Plan: Continue with plan of care and home carryover program. Follow up with the client’s physician on results of her follow up videostroboscopy. Plan for additional family education about vocal hygiene strategies and use of a microphone for upcoming speech and debate competition.
Using SOAP notes with your EHR
As most SLPs know, documentation is necessary but not always the most rewarding. However, having an EHR that lets you load previous notes and reference past activities or the status of your clients’ goals can help you save time and simplify your documentation.
Whether you take notes after sessions or schedule time at the end of the day, we hope these examples will help build confidence around the important work you’re doing to help your clients.
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