SOAP Notes Fall 2015

S-Section Comment on how client participated in therapy Important events since last session Medical issues Completion of homework Caregiver/parent training or information provided?

S-Examples Mom commented: “Yesterday I heard her say her brother’s name correctly for the first time.” Mom reported that R has a bad cough. She plans to take him to the doctor this afternoon. Ali’s mom asked if she could get more pictures to practice at home.

O-Section Report data related to your session objectives Different ways to report data in O section – Narrative – Table format – Bullets

Example of Objective Data Narrative Production of /sk/ was 75% correct (15/20) given a verbal model when naming picture cards in a matching game. This compares to 50% (10/20) during last session. Tammy would typically simplify the cluster /sk/ to /k/.

Example of Objective Data Table Format Short Term Objectives Baseline 4/25/15 Previous Session 5/1/08 Current Session 5/5/08 Comments Consonant cluster /sk/, initial position in words given a verbal model 3/10 (30%)10/20 (50%) 15/20 (75%) Used consonant simplificati on /k/ for /sk/

Example of Objective Data Bullets Target: Consonant cluster /sk/, initial position in words given a verbal model – Accuracy for current session 75% (15/20) – Accuracy for last session: 50% (10/15) – Error pattern: Consonant simplification (k for sk)

Example of Objective Data Bullets Target: Consonant cluster /sk/, initial position in words given a verbal model – Accuracy for current session 75% (15/20) – Accuracy for last session: 50% (10/15) – Error pattern: Consonant simplification (k for sk)

A-Section Analysis and interpretation of data – Change from previous session – Effectiveness of cues or strategies – Explanation of success or difficulties No new information in A section Avoid restating data from S and O sections Avoid “speculating”

Example of A-Section Tammy improved her ability to produce /sk/ given a verbal model over the course of the last two sessions.

P-Section Plan for next therapy session – Be specific about planned adjustments in target level, level of cueing, activities or homework – If you win the lottery rule Note client’s homework for next session Note any – Additional testing needed – Referrals needed

Examples of P-Section Continue with Cycles approach: – New cluster: /sp/ – Continue with /sk/ Use picture agenda and simple reward system to keep Tammy focused on task Tammy to say 5 words with /sk/ every day at home. List of games/activities was given to Tammy’s mom.

Explain Technical Terms and Acronyms The Goldman-Fristoe Test of Articulation–2nd Edition (GFTA-2) is a norm-referenced, standardized test that focuses on how a child says individual sounds by targeting each sound in each word position. The child is asked to name objects in pictures that contain the targeted speech sounds.

Words to avoid Observed Monitored Practiced