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SOAP Note Example 2

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SOAP Note Example 2 Page 2
SOAP Note Example 2
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Fluency
S:
Client reported reduction in overall fear level and tension in neck area during oral presentations in
group meetings at work this week. Client is concerned abo
ut a telephone conference call
scheduled
for next Tuesday at work.
O
: Client will monitor retrials during a two
-
minute monologue with clinician with 90% accuracy over 2
sessions, 12/30 = 40%. Client will make 2 phone calls per week in a bystander situatio
n at work as reported
in 3 homework logs, 6/6/08, 6/8/08 = goal met this week. Client will use pull
-
outs in 50% of opportunities
during a two
-
minute conversation with the clinician, 4 pull
-
outs/6 opportunities = 66%.
A:
Client continues to demonstrate dif
ficulty distinguishing between core repetition and retrials.
Also,
he may be observing retrials but not signaling consistently.
Pull
-
outs on fixations
met target
criteria, pull
-
outs on laryngeal closures did not.
P:
Use gestural prompt to aid signaling du
ring monitoring, then fade. Add direct modeling for pull
outs
on laryngeal closures.
Auditory Comprehension
S: John appeared alert today. He greeted the clinician with a smile.
O: The client responded to 20 yes/no questions with 70% accuracy.
A: John d
emonstrated progress in both treatment tasks today. Response to yes/no questions increased
60% to 70% (in 20 trials). Imitative.
P: Continue current activities.
Articulation
S: Client seemed less responsive today and difficult to engage.
O: Produced f
inal consonants at sentence level with 85% accuracy during a structured activity. Produced
/s/ in all positions during conversational speech with minimal auditory cueing.
A: Jason’s progress on /s/ production objectives suggests he is beginning to master
this skill. Skill is still
present when visual and auditory cueing is reduced.
P: Plan to continue working on final consonants and baseline accuracy in structured speech activity.
Remove all cueing during /s/ activity to see if successful production can
be maintained.
Language
S: Client arrived on time and appeared ready and motivation to begin therapy.
O: Across a 55
-
minute session, client produced spontaneous utterances 65% of the time with imitated
utterances occurring 35% of the time during struc
tured science experiment activity. Auxiliary verb
production worksheet was completed with 76% accuracy (19/25) following a book reading task with a high
occurrence of auxiliary verb usage. Binary choices were given X6 when erred productions were made.
A:
Spontaneous productions have increased by 5% over last week (averaged 60% spontaneous; 40%
imitated). Eric seemed more confident during in offering inferences during the science experiment activity.
Binary choices seemed to help Eric correct erred producti
on of auxiliary verbs during worksheet activity.
P: Continue use of science experiments to increase Eric’s use of spontaneous expressive utterances.
Continue to target auxiliary verbs using book reading activities and decrease amount of scaffolding given
.
Prepare home program to be completed over spring break to decrease regression over break.
SOAP Note Example 2
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