Speech and Language Pathology

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Help with SOAP notes and SIPS
summersaultz1 wrote in speechpathology
Hello everyone. I just started grad school and thus far i'm having some trouble with my SOAP notes. We never really had any training on how to do them, we were just given an example and told to model our notes after it. However, we all seem to be doing pretty bad, but then again if we were never taught what do they expect? Does anyone have any websites that show you how to write soap notes? I think I'm having the most difficulty with the assessment portion. What exactly should I include in it?

Do most programs teach you how SOAP notes should be done, or is providing an example and expecting students to learn it on their on standard? So far i'm pretty disappointed in my program but maybe this is just what all programs do.

Thanks in Advance for help :)

I'm still doing undergrad work but we're supposed to learn how to do SOAP notes next week. We're going to get a lot of training in them. Up until then, can't really help you :-( Just out of curiosity, what program do you go to?

Assuming your talking about therapy SOAP notes and not Diagnostic SOAP Notes (which are a bit different - and I'm sure there's people here who can give better examples because I don't DO soap notes anymore really)...it goes:

Subjective: how they came in. (X separated easily from Mom and interacted well with the clinician. OR X had difficulty separating from Mom and cried off an on the whole session.)

Objective: What you hoped to accomplish and the numbers. (Following directions: 3 step - 30%, 2 step - 70%, 1 step - 100%. OR /sm/ word initial - 100% with tactile, visual cues. /sp/ word initial - 100% visual cues)

Assessment: What it actually means - did they improve, did they worsen, are you using fewer cues. (Following 2-step directions improved X%, 3-step directions still difficult. Additional cueing needed. OR /sp/ improved X%, continued stopping on /sm/ without visual and tactile cues.)

Plan: What you're going to work on next week.

The Objective part is all about numbers. What did they client actually DO. Assessment is what does it mean - was it typical, did it improve, did one lead to the other - and where was the breakdown.

Remember: SOAP notes are supposed to be very VERY succinct - telegraphic speech is acceptable as long as it's clear. We were taught everything fits on 1/2 page (for tx SOAPs, 1 page for DX soaps).

Hope that helps.

It REALLY does, thanks so much!!

I am a 1st year grad student too and just had to write my first SOAP note. We never "learned" how, they gave us an outline. The above outline is great, the only different thing on my outline is in the objective part we are supposed to write receptive/expressive language and long/short term goals.

Hope that helps!

I'm doing an intro to clinical methods this semester (I'm an undergrad) and the above outline is pretty much what we've been taught to do for our SOAPs. My notes always turn out super-long, but that's likely because my teacher is sort of anal and wants lots and lots of details right now. They're supposed to get shorter, I think.

The length of notes will depend on what is being worked on. For instance,someone with an artic goal the note will most likely be very short. Someone with an AAC device will be longer. Someone who is non-verbal and you're having to scaffold, will have longer notes. Phono (if you're doing CYCLES) will be a medium length because it's automatically 100% success rate - but you have to document what types of cues/prompts are needed.

Great run-down on SOAP notes for beginners :)


2010-09-19 06:06 pm (UTC)

You are so helpful, this really helps a lot!!!

That's actually really interesting and helpful. I'm just learning how to write notes (writing one as we speak...) so cool. :)

Awesome outline, Montana Mary!

In my undergrad, we had to write SOAP notes for various clients we saw via video for practice. We weren't really "taught" how to do it.

In mine, I generally lay it out like this:

S: Anything the parent noted/how the kiddo acted, appeared, if they had behavior issues, etc.

O: Goals listed with percentages, data, etc.

A: Describe what the goals mean, any improvement, types of cueing used

P: Plan for next time, adjusting cues/artic positions, etc based on what happened in O/A

SOAP notes should always be written in past tense form, also.

My undergrad professor wanted long, detailed notes, but my grad professors wanted more short-to the point notes. And now, in my offsite, they're even shorter and easier to write/read. =)

Good luck!

I had forgotten about the need for past-tense form, it's automatic now, I had forgotten how challenging it was when I started! The only "SOAP" (if you can call it that) that I write now is for Medicaid billing. It's 3 lines long for EVERYTHING so it's VERY short and succinct. Thankfully it's for less than 30% of my caseload.

For me, it helped when I realized the whole reason for SOAP notes was to facilitate billing for insurance/etc. Short, sweet, and to the point to show what you're doing and whether or not the therapy the insurance company is (supposedly) paying for is working.

My program asked us to purchase, The Survival Guide for the Beginning Speech-Language Clinician, and gave us a half-day seminar on SOAP notes. I really recommend this book as I use it for a reference quite frequently for my placements (and it's useful for other things besides SOAP notes).

My supervisors also gave us examples of SOAP notes and other reports. I find that I've learned a great deal from the experience of writing them and receiving their feedback. As you get more practice writing SOAP notes and reports it will get better.

slp soap notes


2011-03-01 11:59 pm (UTC)

I am in my clinical placement now and my program only gave a format...thats fine but doesnt fit real life situations.

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