Exam 1- Soap Notes Flashcards
1
Q
What are SOAP notes?
A
Brief, informative notes that focus on what others need to know about your sessions.
- Include whatever an insurance company would need to see in order to justify your continued involvement with the patient.
2
Q
What does “SOAP” stand for?
A
S = Subjective O = Objective A = Assessment P = Plan
3
Q
S = Subjective
A
- Describe your impressions of the client. Include client’s level of awareness, motivation, mood, willingness to participate, etc…
- Also list anything the client and/or family may say to you during a session.
E.g., “G.W. appeared alert and cooperative. He stated, “I’m ready to work hard today.”
4
Q
O = Objective
A
- Write MEASURABLE quantitative information; your data.
- Test scores and percentages for any objectives worked on.
5
Q
A = Assessment
A
- Describe your analysis of the session
- *The interpretation section
- Compare the client’s performance across sessions
6
Q
P = Plan
A
- Outline the course of treatment.
- Include any changes to objectives, activities, or reinforcement schedules.
E.g.,
a) Continue current treatment activities.
b) Continue training production of functional CVC words at the phrase level.
