Speech therapists provide rehabilitative services.
Healthcare providers are required to document information about patient encounters. These notes are typically written after each treatment session. The acronym SOAP describes the information that should be contained in the treatment note. SOAP stands for subjective, objective, assessment and plan. Speech and language pathologists use SOAP notes to document the patient's comments and symptoms before treatment, interventions performed during the treatment session, the patient's response to treatment, and plans for subsequent visits.
Instructions
1. Type your SOAP notes or write legibly. Notes are frequently sent to insurance companies along with the bill for services rendered. Include the patient's name, medical record number and the date of service at the beginning of each note. Use black ink only when documenting by hand. Draw a single line through errors, write the word error and initial.
2. Begin each section of the note with the corresponding letter of the SOAP acronym. Begin with S and document the patient's subjective comments first. Include the patient's symptoms, whether they are improving or getting worse and any other information offered by the patient or their family that is relevant to speech therapy goals. Patient's wife accompanied patient to therapy today. She states that he is beginning to verbally respond yes or no when she asks him a question, is an example of a subjective note.
3. Write the O section of the note next. Include all objective information -- interventions that were performed, measurements taken and test results. Matching exercises were completed with 80 percent accuracy. Oral identification activities were performed using pictures of common objects, is an example of an objective note.
4. Document the A section of the note including the patient's response to the treatment delivered that day. Comment on the patient's progress or lack of progress related to the goals set at the initial evaluation. Write new goals or changes to existing goals in this section as well. Patient is progressing with his receptive and expressive language skills and is able to communicate appropriate 'yes' and 'no' responses to basic questions, is an example of an assessment note.
5. Plan future treatment interventions and document them in the P section of the note. Address the duration and frequency of treatment as well. An example of a planning note would be, Continue speech therapy two times per week to improve language and communication skills. Progress patient's home exercise program next visit.
Tags: write, speech, language, soap, notes, section note, document patient, Include patient, patient response, patient response treatment
