SOAP Notes for Speech Therapy: The Ultimate Guide

  • Monday, July 12, 2021
SOAP Notes for Speech Therapy, speech therapy soap notes, soap note, speech therapy soap note, speech therapy

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.

Subjective

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.

 Objective

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)

Assessment

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.

Plan

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.


Resources
online games for speech therapy, online speech therapy game, free online therapy games, teletherapy games, teletherapy, telehealth

7/15/2020

Online Speech Therapy Games

Online speech therapy games are great for home practice and teletherapy (aka telehealth) and add another mode of learning. This blog will review 12 fun online speech therapy games and resources that therapists can utilize with children either during office or telehealth visits.

psychology magazines, top psychology magazines, psychology journals, Magazines for Therapists, Journals for Therapists, Top Psychology Journals, Clinical Psychology, Psychoanalysis, Family Therapy, Developmental Psychology

6/7/2021

Top Psychology Journals and Magazines for Therapists

Looking for the latest latest psychology research and news? Browse our list of the top Psychology Journals and Magazines for therapists. Some of these are rigorous academic journals but many are popular magazines that contain more accessible information

Teletherapy e-book

Subscribe to our blog

    Blog Categories
    Resources
    Teletherapy
    Law
    Telepractice
    Marketing
    Getting Started
    Press
    Behavioral Therapy
    Insurance
    Case Studies

    Latest Posts

    • Where Occupational Therapy and Mental Health Meet

      Friday, September 17, 2021

      Occupational therapy has a strong historical connection to mental health.  Therapists can work with individuals and populations in a variety of settings to promote positive mental health.  Several OT skills that we use in multiple environments can be easily adapted to support mental health populations. 

    • Top Occupational Therapy Blogs of 2021

      Thursday, September 2, 2021

      TheraPlatform aims to provide occupational therapists with the best resources and has created this list of occupational therapy blogs making waves in 2021.  Blogs were selected based on excellent content, unique insight, potential applicability to the reader’s practice, recent activity, and overall quality. 

    • The 10 Principles of Recovery

      Friday, August 27, 2021

      In 2010, the Substance Abuse and Mental Health Services Administration (SAMHSA) created an expanded definition of recovery to include people who are both suffering from addiction and mental health illnesses.  The principles of recovery apply to both populations.  Therefore, the content of this article pertains to both individuals recovering from mental health illness and addiction.

    Download FREE Resources
    Anger Management Worksheets
    Anxiety Worksheets
    Couples Therapy Worksheets
    Self-esteem Worksheets
    DBT Worksheets
    Therapy Notes Templates
    Emotional Literacy Worksheets
    Addiction and Recovery Worksheets
    Group Therapy Worksheets