Tuesday, October 11, 2011
As I continue to get more comfortable in my role/job as a speech therapist, one thing I constantly find I need more of is... TIME!

Time is a hot commodity for SLPs. I have a caseload of about 40 kids I see individually in private therapy. I have to plan and print work for almost every one each week, and after each session I must complete a note that documents their progress. This kind of note is called a SOAP note. SOAP notes are used across the medical field, and we are no exception.

S - Subjective
O - Objective
A - Assessment
P - Plan

S -- In the subjective section, you give your subjective opinion about the client. This is where information about behavior would go. Was the child super duper or a stinker? Explaining in detail can help you to see patterns of behaviors. For example, if Child A had a tantrum every time that the parent came into the therapy room, I could see this and request that mom/dad step out.

O - In the objective section, we give information that is not based on opinion. For example, we would say what the treatment would included, if parent instructions were provided, etc.

A -In the assessment section, we assess how their work was for this session. Usually these needs to be stated in relation to their goals. For example:

Pt. will identify colors in a choice of two - 5/10 times; minimal cueing

You would want to be sure to document as clearly as you can the progress the child makes in a measurable way. If a child has not reached a goal, but is clearly making slow but steady progress, you will be able to see this in your assessment numbers. This will help you to readjust your goals as necessary. This is also where you would want to add information about how the child achieved this -- was it with minimal cueing or max cueing? Was it done independently (AKA spontaneously)?

You should document both long term goals (ex: increase receptive language skills) and short term goals (like the example above).

P - In the plan section you should document future plans for treatment. For example, when will the client return for therapy?

The A/P sections can kind of blur together a bit -- in some instances, I've seen long term goals only documented in the P section as it is a future plan. This is a rough outline for a format I use.

Currently, my company uses a template/checklist style list. We can check off for attitude, who the client was with, what treatment was included, etc. We still have to manually write out the information for each goal that was addressed. I'm hoping to think of a way to digitize this information so that we can simply do everything on a computer as a checklist. We will have to print the SOAP notes as we have a paper based system and not electronic, but the time I spend checking things, or writing out the goals feels like a waste of time.

If I find a good system for making a SOAP note that will automatically fills in your goals in the correct format, I will certainly share. If you are an SLP out there in the "interwebz" that has a good program they are in love with, please share!

Off to head home... hoping to get in some time with my new hobby (knitting)!