Lecture 3: Documentation Flashcards
Why are lesson plans important
They guide your session and allow for structure in documentation
Main components of a lesson plan
- clients name
- DOB
- date of session
- number of session
- short term objectives
- activities
- superstep and substep
What does SOAP stand for
S: Subjective
O: Objective
A: Assessment
P: Plan
What does subjective stand for
concerns of individuals or family members
“Johnnys mother reported that he has not been feeling well”
What does objective stand for
summery of data collected in session
“Johnny produced ‘s’ in initial position of words with 80% accuracy”
What does assessment stand for
Compares subjective and objective sections and compares progress across sections
“Use of the present progressive verb tense increased from 75% to last session to 83%”
What does plan stand for
Course of action to be followed
Must demonstrate the pursuit of the treatment plan
“Continue working with elicited word level”
Can you sign off on your own reports?
No, the SLP needs to
When are progress notes written
At the end of therapy
When are discharge reports written and by who
The SLP writes them when the client is no longer receiving therapy
What are the guidelines for writing progress reports
- Give clients identification information
- describe the period of time covered in the report
- number of sessions attended and absences
- the length of treatment sessions
- describe each goal separately
- describe clients performance of each goal using data collected from sessions
- End with your name, title and signature
Role of CDA before therapy
Ensure you are clear on individual objectives and treatment plans Discuss questions with SLP Prep and organize materials Set up therapy room Have data sheets ready
Role of CDA during therapy
Implement the recommended treatment Establish rapport with client/caregiver Provide instructions that are clear and age appropriate Manage behaviour Use feedback reinforcement Collect data
Role of CDA after therapy
Summary notes
Return materials and clean up
Inform SLP of questions, concerns and progress
What is the general therapy progression
imitation – elicited – spontaneous
structured — unstructured
prompted – independent
