SLP SOAP Notes - Progress notes for patient's sessions

SOAP Notes are used by Physicians at the end of the client’s session to keep track of their progress through each session. It’s best to be brief, informative, and focus on what other physician, caregivers, or insurance companies would need to see to continue treatment.

It’s best to keep everything short and simple. (2-3 sentences for each section)

The information includes: Subjective, Objective, Assessment, Plan (SOAP)

Subjective –

A brief statement that describes the client’s state from the clinician’s point of view.

(Client’s behavior, medical status, and psychological state.)

Objective –

Information that is measurable or quantitative. Including reporting therapy goals and client achievement for each session. (Percentage, accuracy, scores, etc.)

Assessment –

Analyze and interpret information from the Subjective and Objective sections. (Is the client making progress? Any obstacles that need to be resolved?)

Plan –

The Clinician writes the recommended next steps for treatment. (Changes to treatment plan? If so, why? Should the client be discharged from speech therapy? Another other communication therapy services recommended to the client?)