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SOAP Note Example 2

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SOAP Note Example 2
SOAP Note Example 2
You will write a SOAP note at the end of every session. The idea of a SOAP note
is to be brief, informative, focus
on what others need to know (e.g., doctors, nurses, teachers, OT, PT, social worker, another SLP, etc.), and
include whatever in
the patient.
SOAP notes are turned in with your treatment plans every week. Check with your supervisor for deadlines.
Describe your impressions of the client in t
he subjective section. Include your
impressions about the client’s/patient’s level of awareness, motivation, mood,
willingness to participate. You may also list here anything the patient and/or family may
say to you during a session.
For example: The clie
nt appeared very alert and cooperative. He stated,
“I’m ready to work
Write measurable information in the
section. Your data goes here.
Include any test scores, percentages for any goals/objectives worked on, and any
quantitative inf
For instance:
The client produced four syllable phrases with 80% accuracy in 40 out of 50
Describe your analysis of the session in the assessment section. This is the
interpretation section. Insurance companies like it when you
compare the client’s
performance across sessions.
For example:
(a) Production of /r/ increased from 65% accuracy during the last session to 90%
during todays session. (b) Withdrawal of visual models resulted in a decrease in accurate
of single syllable words from 90% to 65%.
Outline the course of treatment in the
section. Any changes to objectives,
activities, reinforcement schedules should be included.
You might simply state:
(a) Continue current treatment activities. (b) Contin
ue training
of functional CVC words at the phrase level.
Adult Aphasic
S: Patient’s wife: “He seems to be speaking much more clearly today, and seems to understand me better.
O: Client completed word retrieval activities with 70% ac
curacy (7/10) with phonemic cueing needed on 4
items. He followed complex 2
step commands with 60% accuracy (6/10) with visual cueing needed for 2
items and repetition needed on 4 items. He wrote single words with 70% accuracy with no grammatical or
ng errors. Written homework assignment completed with only 2 errors. Criteria for all objectives is
A: Improvement observed in word retrieval and writing activities. Auditory comprehension remains at low
level. Commands may be too hard or clinician’s
presentation may be too fast. Pace of session good.
P: Continue with all current objectives. Review auditory commands before next session. If auditory
comprehension of commands continues to be low, could consider other types of auditory comprehension
tivities. Remember to slow down presentation of commands by noting on data sheet.
SOAP Note Example 2