We know what a SOAP note is. We've been writing them since grad school (maybe even undergrad) but how are yours measuring up? Have you been accurately capturing what occurred in your treatment sessions? Or have you been copying and pasting your way to 5pm each day? (for legal reasons, please don't answer that lol)
I think it's safe to say that the majority of SLPs feel pretty confident in their S section (Subjective), their O section (Objective), and their P section (Plan). Where I get the most questions is regarding the A section (Assessment)... Let's focus on that today.
In my opinion, the O section is the patient's time to shine, whereas the assessment section is YOUR time to shine! You get to really ANALYZE and INTERPRET how the patient is doing in tx visits here..... so do just that, ANALYZE and INTERPRET.
Consider how the patient is doing in context of the goals you all collaborated on for the treatment plan. In what ways are they getting better? In what ways are they getting worse? Is there a particular technique they are responding better to? Are they needing the same cues or support they did initially? Has their speed increased? Are they displaying behavior that indicates they are more familiar or confident with strategies?
There are just a few things that matter when considering an A section. What else would you add?
-Dana (The Neuro SLP)
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