Are you a speech-language pathologist who is new to writing SOAP notes? Or maybe you're more experienced, but you would like to learn how to improve your documentation. Either way, writing effective SOAP notes is an essential skill in speech therapy. Quality of care and reimbursement depend on it.
In this blog post, we'll walk you through the process of writing a great SOAP note for speech therapy, step-by-step, and provide examples of each component. By the end of this guide, you'll be able to create concise but comprehensive notes that effectively summarize your visits and show patient progress.
What are SOAP notes and why are they important for speech therapy?
SOAP notes provide a structure for SLPs to document clinical information about patient visits and outcomes. The acronym SOAP stands for the four main components of the note: subjective, objective, assessment, and plan.
In general, SOAP notes tell your patient's speech therapy story. They include information your patient, their family, and/or caregivers tell you, as well as the observations you make and data you collect during visits.
Additionally, they contain an analysis of the above to determine patient response to treatment and progress in speech therapy. Based on this analysis, they also provide a plan for the next steps in treatment.
In other words, SOAP notes should clearly explain what you are doing in speech therapy and why, whether it is working, and what you plan for the future.
Effective speech therapy documentation is critical to providing high-quality patient care. Because well-written SOAP notes improve communication between therapists and other health providers, they ensure consistency and continuity of care.
Good SOAP notes make it possible for speech therapists to evaluate outcomes of treatment and justify the need for continued service for insurance reimbursement. They can also serve as defensible documentation in the event of a lawsuit.
From start to finish, let's explore how to tackle each section of a SOAP note for speech therapy in more detail.
Subjective
The subjective section of a SOAP note is where the therapist documents the patient's self-reported symptoms, perceptions, and feelings (if it is possible for the patient to communicate this). You can also include information that the patient's family and/or caregivers provide.
Do not rely on only the information patients, family, or caregivers voluntarily tell you on their own. Be sure to ask thoughtful questions and note information that reflects the patient's response to treatment and treatment effectiveness.
Regardless of the source of the subjective data, you should only include information that is relevant to the patient's condition or speech therapy, such as:
Regardless of the source of the subjective data, you should only include information that is relevant to the patient's condition or speech therapy, such as:
- Patient's medical history
- Symptoms or complaints related to the reason for speech therapy
- Perception and feelings about the patient's condition and therapy
- Patient's functional abilities and needs in daily life
- Goals or expectations about speech therapy
- Other information that could impact performance or progress in therapy, e.g., poor sleep
Collecting good subjective data on an ongoing basis is important for recognizing patterns and progress toward goals.
Examples:
Sally states, "In speech therapy, I like playing games the most."
Mother reports that Emily has been practicing her /s/ sound at home and is now able to produce it in words.
Grandmother reports that John's behavior has been much better since starting speech therapy and he is now able to follow simple commands.
Father reports that Sarah has been having a lot of trouble with her /r/ sound and stutters when she gets upset.
Objective
The next step in writing a SOAP note is the objective section. This includes the results of any tests or measurements that were done during the visit, as well as other observations you make during therapy.
It is important to be as specific as possible here. Objective information should be reproducible, meaning that you or another therapist could repeat the tests, measures, and observations to collect the data.
More specifically, the objective section should include:
- Results of speech therapy assessments and measurements
- Description of the speech therapy interventions you provide
- Observations about the patient's function
- Observations about the patient's participation in therapy
- Record of what happened during the visit and number of visits provided
Like subjective data, comparisons of objective data over time can indicate response to treatment and progress toward goals.
Also, be sure to write the objective section so that it can be easily understood not only by speech therapists and assistants but also by other readers, e.g., other health professionals, insurance reviewers, lawyers, etc.
Examples:
Briana was able to correctly identify 75% of pictures of common objects shown during receptive language testing with minimal cues from clinician.
Maya was able to follow simple one-step commands with visual and tactile cues with 80% accuracy.
Damien was able to correctly produce the /s/ sound in isolation with moderate visual cues (clinician model) 50% of the time.
During conversation, Peter produced less than 5 verbalizations and gestured to communicate in 8/10x communication opportunities.
Assessment
The assessment section summarizes and interprets the information you gathered in the subjective and objective sections. This is a key section of the SOAP note because it indicates whether speech therapy is effective for the patient.
While the objective section notes the patient's response to each intervention, the assessment section interprets the patient's response to the plan of care. Statements made in the assessment section should be supported by subjective and objective data.
While the objective section notes the patient's response to each intervention, the assessment section interprets the patient's response to the plan of care. Statements made in the assessment section should be supported by subjective and objective data.
The assessment section can include:
- Progress toward patient outcomes and goals; whether or not a goal has been met
- Lack of progress toward goals, and reasons why, i.e., complicating factors
- Change in functional level or impairment severity compared to the evaluation or previous treatment sessions
- Inconsistencies between the subjective data and objective data, or differences between what is reported and what is observed during the visit
Examples:
Damien's ability to correctly produce the /s/ sound in isolation improved by 10% compared with last treatment session.
Ryan's participation and progress in therapy is hindered by lethargy due to reports of poor sleep for the last two weeks.
Kim met short-term goal to participate in play activities with another person for 5/5 minutes with eye contact and attention with 80% accuracy across 4 therapy sessions.
Plan
Lastly, the plan section of a speech therapy SOAP note describes what will happen next in the patient's treatment plan. This should be based on the information gathered in the subjective, objective, and assessment sections.
Use verbs in the future tense to describe what will be done before or during the next visit. More specifically, this may include:
- When the patient's next visit is scheduled and what will be done to facilitate progress toward goals
- How many visits the patient has remaining before discharge from speech therapy
- Plans to consult with other health providers, e.g., doctor, PT, or OT
- What the patient, family, or caregiver will do to support therapy at home or what they need to do before the next treatment session
- Any resources that need to be prepared before the next visit
- Changes that will be made to the treatment plan, e.g., upgrade goals that were met or discharge ineffective interventions
Examples:
Will see Jenny next session for reassessment.
Continue with treatment plan 3 visits per week for 4 weeks.
Before the next visit, Paul's mother will put a desk in his bedroom to minimize distractions and observe him for 15 minutes per day as he completes assigned activities at home.
Use Ambiki games during next visit to improve Sally's participation in speech therapy and facilitate progress toward goals.
Putting It All Together
By now, you should have a good understanding of how to write SOAP notes for speech therapy. Simply put, gather subjective and objective data relevant to speech therapy, interpret that data in the assessment, and make a plan based on the assessment.
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