2/28/14-SOAP notes

Question 1

What is the purpose of SOAP notes?

Answer 1

the idea of a SOAP note is to be brief, informative, focus on what others need to know (e.g., doctors, nurses, teachers, OT, PT, social worker, another SLP, etc) and include whatever information an insurance company would need to justify your continued involvement with the patient

Question 2

In SOAP notes what does the “S” stand for?

Answer 2

Subjective

Question 3

Describe what goes in the Subjective part of soap notes

Answer 3

S: Describe your impressions of the client in the subjective section. Include your impressions about the client’s/patient’s level of awareness, motivation, mood, willingness to participate. You may also list here anything the patient and/or family may say to you during a session.

For example: The client appeared very alert and cooperative. He stated, “I’m ready to work hard today.”

Question 4

In SOAP notes what does the “O” stand for?

Answer 4

Objective

Question 5

Describe what goes in the objective part of soap notes

Answer 5

O: Write measurable information in the objective section. Your data goes here. Include any test scores, percentages for any goals/objectives worked on, and any quantitative information.

For instance: The client produced four syllable phrases with 80% accuracy in 40 out of 50 trials (40/50).

Question 6

In SOAP notes what does the “A” stand for?

Answer 6

Assessment

Question 7

Describe what goes in the Assessment part of SOAP notes

Answer 7

A: Describe your analysis of the session in the assessment section. This is the interpretation section. Insurance companies like it when you compare the client’s performance across sessions.

For example: (a) Production of /r/ increased from 65% accuracy during the last session to 90% accuracy during today’s session. (b) Withdrawal of 	visual models resulted in a decrease in accurate production of single syllable words from 90% to 	65%.

Question 8

In SOAP notes, what does the P stand for?

Answer 8

P: Outline the course of treatment in the plan section. Any changes to objectives, activities, reinforcement schedules should be included.

For example: You might simply state: (a) Continue current treatment activities. (b) Continue training production of functional CVC words at the phrase level.

Question 9

ON THE EXAM: **

Answer 9

Goal writing

definitely know criteria for goal writing

piaget’s schematic

HIPAA

All about learning

Developmental Domains