SPEECH THERAPY SOAP NOTE

Patient: [Name]
Date of birth: [Date]
Date of session: [Date]
Session: [Number in the current plan of care; length in minutes; in person or teletherapy]
Diagnosis: [Speech, language, voice, fluency, or swallowing diagnosis being treated]
Present: [Patient, parent or caregiver, interpreter, others]
Clinician: [Name, credentials]

SUBJECTIVE
Report: [What the patient, family, or teacher has noticed since the last session, in their words]
Home practice: [What was practiced, how often, and any difficulty]
Changes: [Illness, fatigue, hearing, medication, or schedule changes, or none]

OBJECTIVE
Behavior and participation: [Alertness, attention, cooperation, breaks or reinforcement needed]
Goal 1: [Target and level, correct out of total trials, percent accuracy, cue level and type]
Goal 2: [Target and level, correct out of total trials, percent accuracy, cue level and type]
Goal 3: [Target and level, correct out of total trials, percent accuracy, cue level and type]
Skilled interventions: [Techniques used, cueing hierarchy, and how cues were faded]
Caregiver training: [What was taught, and how well the caregiver demonstrated it back]

ASSESSMENT
Progress: [Each goal against baseline and recent sessions: met, progressing, emerging, or not progressing]
Response to cues: [Which cues helped, and how much support is still needed]
Barriers: [Attention, fatigue, hearing, attendance, or carryover limits, or none]
Skilled need: [Why the patient still needs a speech-language pathologist's skills]

PLAN
Next session: [Targets, level, and cue fading planned]
Home program: [Activities, how often, and who will help]
Frequency: [Sessions per week, session length, and what remains of the plan of care]
Goal changes: [Goals met, revised, or added, or none]
Coordination: [Teacher, physician, audiologist, or other contacts, and re-evaluation date]

Signed: [Clinician name, credentials, date and time]