Speech therapy SOAP note example

A session note from a speech-language pathologist working with a young child on a speech sound disorder. It records accuracy for each target as a count and a percentage, the level of cueing, and the progress toward each goal.

Example SOAP note

Fictional client: Ella S., 5 years 4 months, eighth session for velar fronting, 30 minutes. Any likeness to a real person is a coincidence.

Subjective

Mother reports Ella said "cookie" correctly at home several times this week, and they practiced the word cards on 4 of 7 days.

Her kindergarten teacher has noticed fewer requests to repeat herself. Ella came in cheerful and eager to play.

Objective

/k/ at the start of words: 42/50 correct (84%) with minimal cues (session 6: 60%).

/k/ at the end of words: 30/50 correct (60%) with visual and tactile cues.

/g/ at the start of words: 18/30 correct (60%) with a model.

/k/ at the start of words in the carrier phrase "I see a ___": 14/20 correct (70%).

Intelligibility in conversation, estimated by the clinician for an unfamiliar listener: about 75%.

Approach: minimal pairs ("tea"/"key"), a tactile cue under the chin for the back of the tongue, and a reward game.

Assessment

Phonological disorder (F80.0) with velar fronting.

Goal 1 (/k/ at the start of words, 80% accuracy over 3 sessions): met in 1 of 3 sessions. Goal 2 (/k/ at the end of words): emerging. Goal 3 (/g/ at the start of words): emerging.

Responds well to minimal pairs and the tactile cue. Home practice is helping carryover.

Plan

Continue twice a week, 30-minute sessions.

Next session: /k/ at the start of words in phrases; minimal pairs for /t/ and /k/ at the end of words; begin /g/ at the start of words with minimal pairs.

Home: /k/ word-end cards for 5 minutes a day. Showed her mother how to give the "back of the tongue" cue.

Probe /k/ at the start of words in sentences next session. Update goals at the 12-session progress report.

Why this note works

  • Accuracy is recorded as a count and a percentage for each target, at each level (word, phrase).
  • The cueing level is stated, so 84% with minimal cues reads differently from 84% with maximal cues.
  • Each goal has its criterion (80% over 3 sessions) and a status.
  • The caregiver's report and home practice are documented, which supports carryover.
  • The Plan names the targets for next session and when the goals are reviewed.

What to include in each section

Subjective

  • Report from the client, parent, caregiver or teacher
  • Home practice done
  • Health, hearing, behavior or attention that affected the session

Objective

  • Each target with correct trials out of total and the percentage
  • Level: sound, syllable, word, phrase, sentence, conversation
  • Cueing level (independent, minimal, moderate, maximal) and the type of cue
  • Standardized test scores, intelligibility or swallow observations
  • Approach and materials used

Assessment

  • Diagnosis with ICD-10-CM codes
  • Status of each goal against its criterion
  • What helped and what didn't
  • Prognosis and the need for continued therapy

Plan

  • Frequency and session length
  • Targets and approach for the next session
  • Home program and caregiver training
  • Next progress report or goal update

Write yours with the free SOAP note template

The template opens with the speech therapy prompts. Fill it in and download a PDF, made on your device.

Open the template

SOAP notes in CloudMedico

CloudMedico is practice management software for small practices. Choose SOAP as your visit note format in Practice settings, and every new visit's notes open with the headings Subjective, Objective, Assessment and Plan. Practices in the United States start with SOAP.

Add the visit's diagnoses from the ICD-10-CM list, and add your own visit fields for what your profession records every time, such as a pain scale or the regions treated. Each visit stays on the client's record with their appointments and invoices, and a US practice can make a superbill from the invoice.

Try CloudMedico free for 30 days

More SOAP note examples

Questions

How should an SLP record accuracy in a SOAP note?

Give correct trials out of total trials and the percentage for each target, at the level practiced (word, phrase, sentence), with the cueing level. A percentage without the cueing level is hard to compare between sessions.

Can a speech therapy note include the parent's report?

Yes. What a parent, caregiver or teacher reports goes under Subjective, and it is often the best evidence of carryover outside sessions.

Do school-based SLPs write SOAP notes?

Many do for session notes, alongside the IEP's own progress reporting. Medicaid billing in schools usually asks for a session note with the service, the minutes and the progress made.

Sources

Related