Speech Therapy SOAP Note Templates and Examples

A SOAP note is a widely used method of documentation for healthcare providers. For SLPs, it encompasses a patient’s subjective reports, objective data, an assessment of their condition, and a subsequent treatment plan.

Here are the keys to writing notes using the SOAP format for SLPs:

• Subjective: Document the patient’s subjective impressions of their condition. This includes their personal experiences, feelings, and perspectives related to their speech and language issues.
• Objective: Record observable and measurable data collected during the session. This could encompass clinical measurements, test results, and direct observations of the patient’s speech and language abilities.
• Assessment: Evaluate and summarize the patient’s progress and performance within the session. This is where the SLP synthesizes subjective and objective information to form a clinical judgment about the patient’s current status.
• Plan: Develop a strategic approach for ongoing treatment. This includes outlining therapy goals, determining the frequency of sessions, and planning any home exercises or activities.”

Effective SOAP notes are concise and informative. Here are some tips to write clearly and efficiently:

• Be Succinct: Write short, direct sentences. Use bullet points to list symptoms, observations, and actions.
• Prioritize Information: Start with the most critical information that impacts patient care.
• Use Plain Language: Avoid or explain jargon and technical terms. This makes your notes accessible to all healthcare team members.
• Be Specific: Provide enough detail for others to understand the context. For instance, instead of writing “patient showed improvement,” specify “patient’s stuttering decreased by 10% from the last session.”
• Consistency is Key: Use the same format and order each time you write a SOAP note. This predictability makes it easier to find information.
• Reflect on Objectives: Connect the patient’s progress to the treatment objectives. This shows a trajectory of care.
• Review for Clarity: Before finalizing the note, read it to ensure it’s clear and free of ambiguity or errors.

The SOAP format is not just a procedural tool—it is a strategic approach that offers numerous benefits:

• Enhanced Communication: It promotes clear communication between SLPs and other healthcare providers by using a universal structure.
• Focused Documentation: Each section of a SOAP note serves a distinct purpose, ensuring that documentation is comprehensive yet focused.
• Improved Continuity of Care: Standardized notes make it easier for any practitioner to pick up where another left off, providing continuity in multi-provider settings.
• Efficient Review: The format allows for quick scanning of a patient’s history and therapy progress, which is crucial in time-sensitive clinical environments.
• Goal-Oriented Planning: By clearly outlining assessments and plans, SOAP notes help keep the patient’s therapy goals in focus, ensuring that each session contributes to these objectives.

Here’s a basic template for an SLP SOAP note:

Using the above template, here are some illustrative examples:

Example 1:

• Subjective: Mr. Thompson, a 58-year-old high school teacher, reports increased difficulty projecting his voice during lectures, causing him to feel fatigued by the end of the day.
• Objective: A voice assessment indicates a 15% reduction in vocal volume and hoarseness post-30 minutes of continuous speaking.
• Assessment: Mr. Thompson demonstrates signs of vocal strain, likely related to voice overuse in a classroom setting, which is exacerbated by inadequate vocal rest and poor hydration.
• Plan: Recommend voice therapy focusing on vocal hygiene and relaxation techniques. Advise a minimum of two therapy sessions per week and regular check-ins with an otolaryngologist. Suggest using a classroom amplifier to reduce strain.

Example 2:

• Subjective: Miss Garcia, a 10-year-old with a repaired cleft palate, expresses frustration with classmates having difficulty understanding her speech, particularly during group activities.
• Objective: Articulation assessment reveals compensatory articulation strategies leading to reduced intelligibility, especially for fricative and affricate sounds.
• Assessment: Despite Miss Garcia’s previous progress, residual articulation challenges continue to affect her speech intelligibility and social interactions at school.
• Plan: Plan to enhance articulation therapy with a focus on fricatives and affricates, utilizing visual aids and tactile feedback. Engage in peer-group activities to improve communicative confidence. Schedule sessions twice a week with additional at-home exercises.

Example 3:

• Subjective: Mr. Jenkins, a 72-year-old retiree with recent left hemisphere stroke, reports frustration with word-finding difficulties and his inability to communicate effectively with his family.
• Objective: During a structured naming task, Mr. Jenkins exhibited a 40% occurrence of anomia, with circumlocution observed during conversation.
• Assessment: Mr. Jenkins’ aphasia impacts his expressive language abilities, contributing to communication deficits that affect his daily interactions and quality of life.
• Plan: Initiate intensive aphasia therapy focusing on naming exercises and functional communication strategies. Incorporate family education sessions for communication partner strategies. Schedule therapy four times per week and provide a list of daily exercises to encourage language retrieval practice.

These examples incorporate specific patient details that provide a clearer picture of individual challenges and tailored therapy plans, demonstrating the personalized nature of speech therapy treatment.

The value of the SOAP note in speech therapy extends far beyond the bounds of routine documentation. The SOAP note is an indispensable tool for SLPs, supporting precise documentation and efficient communication among healthcare providers, thereby ensuring quality patient care.