SOAP Notes. Whether you’re a new grad or seasoned clinician, perfecting your treatment note is a crucial part of any Speech Therapist’s practice.
These notes document important data and paint a picture of how the client participated in a session. That’s not always easy. A Speech-Language Pathologist’s (also known as “SLP”) schedule is often filled with back to back clients throughout the day.
Having a clear understanding of what a SOAP note is, and how to write one both thoroughly and efficiently can be a huge help to SLP’s. This helps them feel confident that they documented the necessary information for insurance and legal purposes while not falling behind on paperwork or getting backed up on time.
What is a SOAP Note?
A SOAP note is a written document that reports on what was done in a therapy session. SOAP note stands for the 4 sections that make up the therapy note; Subjective - Objective - Assessment - Plan.
The note is completed after every speech therapy session. It may be shared with the client and/or his or her caregiver, as well as insurance companies.
Here’s a closer look at what makes up a SOAP note, and the do’s and don’ts to keep in mind when writing each section.
This is a brief statement that describes a client’s state from the therapist’s point of view.
The information in this section isn’t measurable, and can be gathered both from the therapist’s observations and any information given by the caregiver who accompanies the client to the session.
What questions can you answer in the subjective section of your SOAP note?
● Behavior (i.e., frequent refusals, cooperative, engaged, attentive)
● Medical status (i.e., recent illness)
● Current state (i.e., alert, lethargic/tired)
Do’s of writing the subjective section:
● Keep it brief (about 1-3 sentences)
● Back up statements with supporting information such as quotes. (For example: Mother reported “he woke up early and is tired today.”)
● Paint a clear picture of how the client participated in the session
Don’ts of writing the subjective section:
● Make it too lengthy.
● Include information that is irrelevant or unnecessary.
Examples of the Subjective section of a SOAP note
Johnny appeared alert, and transitioned into the therapy room without difficulty. He was engaged and participated in all therapeutic activities that were presented.
Alice became upset and clung to her mother upon entering the therapy room. She frequently put her head down and refused to participate in tasks.
Cayden appeared lethargic and his mother reported, “he didn’t sleep well last night”. He was engaged and interactive when provided with positive reinforcement and praise.
The Objective section is all about stating the facts.
The information an SLP writes here must be measurable or quantitative. This usually includes reporting on therapy goals and stating the data that the client achieved for each goal targeted during the session.
When thinking of this section, think percentages, numbers, accuracy level, and scores.
Here, the Speech-Language Pathologist will also state whether each therapy goal was targeted, not targeted, met, not met, or progressing.
What questions can you answer in the objective section of your SOAP note?
● Short term/current therapy goals
● Data reporting the client’s performance on each goal (percentage accuracy or number of times the client performed the targeted task)
● Cueing level provided for each goal (for example, maximum, moderate, minimal cues, or independently)
● If the goal was Met or Not Met for that session
● Number of consecutive sessions in which each goal achieved has been met (for example, 1 out of 3 consecutive sessions)
Do’s of writing the objective section:
● Be clear and concise
● Include measurable data
● Report on the client’s performance
● Address each current therapy goal (if not addressed, mark as “not targeted”)
Don’ts of writing the objective section:
● Don’t include lengthy descriptions of the therapy activities.
● Don’t write subjective information that cannot be quantified
Examples of the Objective section of a SOAP note
Johnny produced the /r/ sound in the initial position of single words with 80% accuracy given moderate cues. (Goal Met for 2 out of 3 consecutive sessions)
Olivia identified common objects in 7 out of 10 opportunities given minimal cues. (Goal Progressing/Not Met)
Allison used irregular past tense verbs at the sentence level with 50% accuracy independently. (Goal Progressing/Not Met)
In the Assessment section of a SOAP note, a Speech-Language Pathologist analyzes and interprets the information documented within the first two sections (the Subjective and Objective sections).
What questions can you answer in the Assessment section of your SOAP note?
● Is the client making progress towards goals overall?
● Are there any barriers to progress? For example, medical status, attendance, or the client’s behavior?
Do’s of writing the assessment section:
● Note client’s response to receiving speech therapy (for example, positive)
● Compare client’s performance to that of previous sessions
Don’ts of writing the assessment section:
● Restate information already reported on in the subjective or objective sections
Examples of the Assessment section of a SOAP note
Ethan continues to demonstrate steady progress towards goals in speech therapy.
Logan’s behavior is impeding his progress towards goals in speech therapy.
Mila’s production of the /th/ sound improved by 15% compared to her previous session.
In this final section of the SOAP note, the therapist writes the recommended next steps for the client’s treatment.
These questions should be answered in the plan section of your SOAP note:
● Is continued treatment recommended?
● Should the client be discharged from speech therapy services?
● Are there any recommended changes to the treatment plan? If so, why? (for example, a reduction in therapy from 2 times per week to 1 time per week due to the client’s progress towards therapy goals).
● Are there any other therapy services recommended going forward for this client? For example, “It is recommended that the client receive a formal audiological evaluation to rule out hearing difficulties”.
When writing the plan section, Do:
● State any recommended changes for the next therapy session. For example, “The next therapy session will focus on recording Alex’s speech and encouraging him to monitor it for articulation errors”.
And the don’t:
● Don’t forget to back up your recommendations.
Write a Superior SOAP Note
Depending on the setting where speech therapy is taking place (hospital, school, or private practice, for example), there may be a specific SOAP note template in place within the Electronic Medical Record system.
Here’s an example of a complete Speech Therapy SOAP note:
S: Johnny appeared alert, and transitioned into the therapy room without difficulty. He was engaged and participated in all therapeutic activities that were presented.
O: Client produced the /r/ sound in the initial position of single words with 80% accuracy given moderate cues. (Goal Met for 2 out of 3 consecutive sessions)
Client used personal pronouns accurately in 6/10 opportunities given minimal cues (Progressing/Goal not met)
A: Johnny continues to demonstrate steady progress towards goals in speech therapy.
P: It is recommended Johnny continue with the current treatment plan of 2 times per week for 30 minutes per session, for an estimated duration of 180 days.
Remember - clear, consistent, and concise are words an SLP should keep in mind when writing a SOAP note.