SOAP Notes for Speech Therapy
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If you’re searching for information on how to write SOAP notes for speech therapy, read on for everything you need to know about soap notes for SLPs.
Keeping tabs on client progress is essential for speech-language pathologists (SLPs), and one of the best ways to track clients’ progress is by using SLP SOAP notes.
The SOAP note format is used by behavioral health therapists, occupational therapists, physical therapists, and many other health and wellness practitioners as a simple and straightforward format to document sessions. For SLPs, SOAP notes for speech therapy achieve those same goals.
SLP SOAP notes enable clinicians to monitor changes in client performance with data, assessing treatment efficacy over time. SOAP notes for speech therapy are designed to give SLPs a simple tool to measure client success.
What are SOAP notes for SLPs?
The acronym “SOAP” describes the four components that make up well-rounded speech therapy notes: Subjective, Objective, Assessment, and Plan.
Together, these four headings give SLPs a common language in their speech therapy materials to describe therapy sessions and chart the course for future ones.
They provide a solid framework for reporting changes in client presentation, treatment strategies, and analysis.
SLP SOAP notes contain a wealth of data: both quantitative and qualitative.
Over time, this type of documentation is vital. It’s important to keep detailed records for both insurance and private pay clients.
SOAP notes justify the client’s need for speech-language therapy while conveying case history and treatment trajectory.
Furthermore, in the field of speech-language pathology, accurate record-keeping falls within the American Speech-Language-Hearing Association’s (ASHA) Code of Ethics.
SOAP notes for speech therapy fulfill this professional responsibility. They create a journal of therapy progress and a roadmap for the future.
How to write SLP SOAP notes
Ready to start documenting? SOAP notes for speech therapy are a breeze. With a little practice, you can follow this straightforward formula and effortlessly keep track of client data.
It’s paramount to understand the type of information that belongs under each of the four headings that comprise SLP SOAP notes. Here’s a quick breakdown:
S – Subjective
This portion of the note is focused on qualitative data. In other words, aspects of the client’s demeanor and presentation that offer valuable insight on their condition. This section may include questions or comments posed by the client, a description of their mood, or other contextual information. The “Subjective” section is also a great place to write down relevant case history or notes from a file review that pertain to an individual session.
O – Objective
This is where you’ll include raw, quantifiable data, the bread and butter of speech therapy notes. Whatever you’re tracking during a session–Mean Length of Utterance, correct repetitions of /r/, number of disfluencies–goes here. If it’s measurable, it belongs under the “O” heading. SLPs may also include other factual data here, such as type of intervention used, specific cues that supported the client, or level of prompting needed.
A – Assessment
Analysis of the client’s performance during speech therapy belongs in this space. The “Assessment” section of SLP SOAP notes includes the SLP’s interpretation of speech assessments. Did the client respond well to a particular type of cue? Was a new treatment method effective, or did it fall flat? This part of the note gives the clinician an opportunity to think critically about how the session went and to consider the bigger picture context of the client’s performance and a speech evaluation for that day.
P – Plan
Looking towards the future, the “Plan” section of SOAP notes for speech therapy includes information about upcoming sessions. If there will be any changes in frequency, goals, or intervention type, the SLP can list those updates here. This sets the tone for the next session and keeps everyone up-to-speed on any modifications to the treatment plan.
Examples of SOAP notes for SLPs
Wondering what SOAP notes for speech therapy look like in practice? We’re breaking down two examples (pediatric and adult) specifically for speech-language pathology clients.
While some aspects of SOAP notes remain universal across disciplines, SLPs are uniquely involved in documenting progress that focuses on speech, language, and swallowing. The field is broad and encompasses a range of disorders and differences; that’s why documentation looks different from one client to the next.
SOAP note example for a pediatric articulation client
Subjective: Client arrived at session five minutes late. Her mother reported she had trouble falling asleep last night and had been “a little cranky” this afternoon. Although initially reluctant to separate from mom, the client expressed enthusiasm about playing UNO and willingly engaged with the clinician when she saw the game on the therapy table.
Objective: Session focused on production of vocalic /r/ at the sentence level using picture card prompts and a cueing hierarchy. Paired articulation drill with UNO card game to increase client motivation.
Client produced /er/ with 75% accuracy in sentences given minimal verbal cues (one clinician model of /er/ word in isolation).
Client produced /or/ with 60% accuracy in sentences given minimal verbal cues (one clinician model of /or/ word in isolation).
Client produced /ar/ with 50% accuracy in sentences given moderate verbal cues (2-3 clinician models of /ar/ word in isolation and in sentence context).
Assessment: The client is making consistent progress with production of vocalic /r/ in the initial, medial, and final positions of words in sentences. She benefits from a clinician model of words before producing them independently, especially when targeting /ar/ words. Client is not yet generalizing production of vocalic /r/ to conversational contexts. She is stimulable for all forms of vocalic /r/ when given a clinician model. Client appears to benefit from reinforcers (e.g. preferred games, like UNO) when targeting sounds.
Plan: Continue with plan of care, targeting vocalic /r/ at the sentence level with scaffolded prompting. Send home a list of 10 target /r/ words to practice this week. Encourage client’s parents to model clear production of vocalic /r/ during home practice.
SOAP note example for an adult fluency client
Subjective: This was the client’s first session with a speech-language pathologist. He shared that he had been “avoiding speech therapy” for much of his life, but felt “ready” to address his stutter. Client appeared anxious when sharing case history. He shared that he has been stuttering “for as long as he can remember,” but that recently, it has been having a more significant impact on his life.
Objective: After obtaining case history through a series of questions in conversation, the client was assessed using the OASES. Client received a raw score of 309 and an impact score of 3.09 on the Overall Impact scale, indicating that disfluent speech has a moderate-to-severe impact on his life. Throughout the evaluation, the clinician observed frequent part-word repetitions, prolonged sounds, and blocks when the client responded to questions.
Assessment: Initial assessment and case history focused on evaluating the negative impact of stuttering on the client’s quality of life. Findings reveal stuttering significantly affects the client’s participation in activities of daily living. The client reported difficulty initiating social interactions in the workplace and avoidance of family events where stuttering might be triggered. He expressed interest in confronting challenging situations and reducing avoidance with clinician support.
Plan: Clinician will further assess client using the Stuttering Severity Instrument at the start of next session. Based on today’s findings, future sessions will incorporate a Cognitive Behavioral Therapy approach to treatment alongside mindfulness and avoidance reduction techniques for stuttering.
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