SOAP notes & Obj. Goal Writing

Question 1

What is the idea behind SOAP notes?

Answer 1

To be brief, informative, focus on what others need to know and include whatever information and insurance company would need to see to justify your continued involvement with client

Question 2

What does the “S” stand for?

Answer 2

Subjective

Question 3

What does the “S” consist of?

Answer 3

• Describing your impression of the client.

- Include your impressions about the client’s level of awareness, motivation, mood, willingness to participate

Question 4

What does the “O” stand for?

Answer 4

Objective

Question 5

What does the “O” consist of?

Answer 5

• Writing measurable information
• Data goes here
• Include any test scores, percentages, for any goals/objectives worked on
• Include quantitative information
• Key words; measurable, accuracy, percentage, or attempts
• Make sure to include the condition (settings)

Question 6

What are some specific words you can use in the objective section?

Answer 6

• Pointed to
• Maintain/complete
• Said
• Smiles
• Exchanges
• Ask
• Comment
• Answer
• Demonstrated

Question 7

What does the “A” stand for?

Answer 7

Assessment/Analysis

Question 8

What does the “A” section consist of?

Answer 8

• Describe your analysis of the session
• Mastery or progress
• This section you are interpreting the data to tell what it all means & how their progress is doing
• EX: “Production of /r/ will increase from 65% accuracy during last session to 90% accuracy during today’s session.”

Question 9

What does the “P” stand for?

Answer 9

Plan

Question 10

What does the “p” consist of?

Answer 10

• Outline the course of treatment
• Any changes to objectives, activities, reinforcement schedules should be included
• Make sure to include continue plan of treatment (POT), focus on …. (i.e. prompting)
• EX: Change objective #1 to receptive from expressive so probe expressive for obj #1

Question 11

What are the 3 critical elements in the objective/goal writing?

Answer 11

1) Performance/behavior = measurable
2) Conditions=context
3) Criterion = accuracy

Question 12

What does the performance/behavior mean?

Answer 12

Helpful tool is to know what the baseline is, if I know that then I can tell you what I want to notice in the end

Question 13

What does the conditions include?

Answer 13

• It is the context, so what you do
  1) prompts you are going to give, get more independent
  2) environment you are in, conditions

Question 14

What does the criterion include?

Answer 14

• it’s the accuracy
• Correct productions out of total opportunities
• % accuracy –> what’s your target percent

Question 15

What are the goals?

Answer 15

• what the client will do what behavior, to what extent and for how long

Question 16

What is the performance?

Answer 16

• an observable, measurable behavior that is desired to be changed

Question 17

What are the methods in objective goal writing?

Answer 17

• How will you teach the client the target behavior

Question 18

What are the materials in objective goal writing?

Answer 18

• A list of the items you will use in the therapy session.

Question 19

What is reinforcement in objective/goal writing?

Answer 19

• A method to positively reinforce the occurrence of target productions (or at least encourages shaping of target).