Writing Effective SOAPs

1. Writing Effective SOAPs Heidi Iwashita, M.S., CCC-SLP Updated for Fall 2018

2. Overview • Subjective • Objective • Analysis • Plan

3. You have learned those terms, but…

4. Why do SOAPs? In professional practice: • Record services provided • Document how you used therapy time • Individualized for the client • Working toward functional outcomes • A reference for other professionals • Record data for your later reference

5. Why do SOAPs? For students: • All of the above, plus more! • Your own skill development • Opportunity for supervisor feedback • Perfecting your clinical writing • Essential vs. non-essential information • Clinical thinking and planning skills

6. Good Documentation Matters! • Clinical documentation • SOAPs/session notes/daily notes • ITPs/ recertification reports/monthly progress reports • Assessment Reports • In many settings, discharge reports

7. A good SOAP is CUT • Complete • Unambiguous • Truthful

8. A good SOAP is CUT • Complete • Unambiguous • Truthful

9. Key Points

10. Writing for a general audience

11. For all documentation, use past tense Right Wrong “Sheila shows insight into factors that improved and hindered her motivation.” “Jason has difficulty with the /s/ sound.” • “Sheila showed insight into factors that improved and hindered her motivation.” • “Jason articulated /s/ correctly in 1 out of 15 attempts during the session.”

12. S: Section S: Section

13. S: Subjective • Briefly describe the client’s main problem or symptoms • What did they say has been happening? • “Julia reported that she has been ‘losing her voice’ in the evenings for the past few weeks.” • Include onset, duration • If possible, include a direct quote by the client or family member • E.g. “I’m having trouble remembering people I’ve met before” • The patient’s “chief complaint” in his/her own words (direct quote) • Alleviating/aggravating factors? • Who else is attending the session? • Client’s attitude/demeanor during the session?

14. SOAP Notes – S: section – General Tips • Who else is there? • Who said what? Attributing statements correctly • “Reported” • “Noted” • “Stated” • “The client seemed in a good mood” vs. “the client was in a good mood.” • Generally keep the S: section short. • However, if there were complicated or serious issues, document that you followed up correctly.

15. SOAP Notes – S: section – General Tips • Most importantly, in the S: section, CAP • Clarify any ambiguities • Attribute statements correctly • Put our minds at ease – don’t make us worry unnecessarily about the client! If there was cause for concern, how did you address that?

16. SOAP Note examples – S: Section When there is something out of the ordinary reported by the client • S: TTT and his mother, Mrs. T, arrived ten minutes late to his scheduled appointment. His mother reported that TTT experienced significant pain in his foot over the break, but is now doing “much better.” • S: OOO reported that she was diagnosed with type II diabetes during the past week, and it has been “very stressful” for her.

17. SOAP Note examples – S: Section • When there is nothing out of the ordinary, what would that look like?

18. SOAP Note examples – S: Section • S: Ms. R arrived to today’s session on time with her husband Mr. R, who stayed in the lobby. Ms. R indicated that she is still having difficulty with word-finding, especially for proper names. She seemed to be in good spirits and readily engaged in conversation with the clinician and the clinical supervisor for the entire session.

19. SOAP Note examples – S: Section

20. SOAP Note examples – S: Section • S: Mr. Q joined Ms. Q in the session. Ms. Q reported that, since her stroke, she always feels “stuffed up to [her] neck.” She, therefore, does not eat during the day but does not report having difficulties with swallowing. In response to follow-up questions by the clinician, she clarified that she has not lost weight, that she eats at night, and that she takes a multivitamin. Ms. Q expressed desire to meet with a neurologist, and the clinician encouraged her to follow up with her physician for a referral. Ms. Q and her partner, Mr. Q, also reported that she displays symptoms of Obsessive-Compulsive Disorder (OCD), but she has not been formally diagnosed with the disorder.

21. O: Section • O: Section

22. O: Section: Purpose • Data! • What did you find out during the session? • Client performance • What you learned from an interview • Results of informal or formal assessments

23. General Tips • Always state what the client DID, not what they WERE ASKED to do. EXAMPLE • “The client was asked five comprehension questions based on cooking instructions presented in ORLA treatment” Should be “The client responded to five comprehension questions based on cooking instructions presented in ORLA treatment”

24. Avoid Making Yourself a Passive Bystander Examples of passivity: “The clinician will monitor for….” “The clinician observed the client perform two trials with the device…” “The first hour of the session was spent discussing the client’s feelings about…” Remember you are providing a SKILLED service! Even while watching and talking with the client, you are using your clinical skills to ASSESS, TREAT, TRAIN, TEACH, CHECK, MODIFY, PROVIDE, etc…. Use active verbs!

25. With Tables • Tables are a clear way to present quantitative data • It’s good to include previous scores for comparison when you can • Dates should go across the top, not down to the side, with the most recent date on the right • If you use codes like “M” “C”, “+”, etc., be sure to include a key at the bottom of the table designating what these mean • The reader’s eye tends to move from left to right, and we expect the most important and easily interpretable information to be on the right side of the table—e.g. percentages, or severity ratings such as “mild”. • You don’t need to type out each individual item/question you asked

26. Example table - typing

27. Without Tables • The O: section can also contain objective information in sentence form • Describing objectively what happened in the session • E.g. what you learned from an interview • Can break up into subsections • Focus on information relevant to assessment/treatment goals • If the objective information will be reported elsewhere, e.g. an Assessment Report, you can just refer the reader to the Assessment Report dated (date) for results.

28. A: Section

29. SOAP Notes – A: Section – Philosophy • “The SOAPs are like chapters of a book and each term is a volume of the book, telling the story of that person.” – Alex Ledbetter • “The ‘why’ of the O” – Susan Boettcher • “The mirror of the self-reflection, this time for the client; what they need in order to do better next time” – Heidi Iwashita

30. What to Include in the A: Section

31. CREW • Client response • Reasons • Explanations • What to change

32. SOAP Notes – A: Section – General Tips • Don’t repeat information already in your O: section • Make sure it follows logically from your data and what you observed in the session; it should not be speculation coming out of nowhere. • It should progress logically from the O: section and into your P: section. So if you identified some ways to adjust your treatment based on the client’s performance today, you would explain that in the A: section, and include your steps for following up on that in your P: section. • It should include the client’s response to your intervention. Insurance providers are now looking for that as evidence that therapists are actually providing a skilled service by customizing therapy tasks to the individual.

33. Let’s look at some examples. In each example, identify: • Client response • Reasons/explanations • What to change (if applicable).

34. A: Compared to the previous session, YYY required less intensive cueing to place his fingers on the home row keys. However, he experienced more difficulty with limiting the keys pressed to the target keys. This may have been a result of the change in computer or associated with his reduced fine motor control, reported by his mother, since the SMART attack. Similarly, the accuracy that YYY achieved on the AIM drill may have been affected by the change in computer or difficulty with fine motor control. It will be useful to assess YYY’s performance on these tasks using the normal computer during the next session. It may also be useful to have YYY try to use an external mouse (rather than the buttons on a laptop mousepad) to complete the AIM drills. YYY’s lack of strategy use during the AIM drill suggests that more time should be spent evaluating the strategy that is best-suited for him, and giving him concrete examples.

35. Red- client responseBlue – reasons for client’s performanceGreen – how to adjust tasks • A: Compared to the previous session, YYY required less intensive cueing to place his fingers on the home row keys. However, he experienced more difficulty with limiting the keys pressed to the target keys. This may have been a result of the change in computer or associated with his reduced fine motor control, reported by his mother, since the SMART attack. Similarly, the accuracy that YYY achieved on the AIM drill may have been affected by the change in computer or difficulty with fine motor control. It will be useful to assess YYY’s performance on these tasks using the normal computer during the next session. It may also be useful to have YYY try to use an external mouse (rather than the buttons on a laptop mousepad) to complete the AIM drills. YYY’s lack of strategy use during the AIM drill suggests that more time should be spent evaluating the strategy that is best-suited for him, and giving him concrete examples.

36. A: Though LLL could not initially recall the order and Step One of the strategy introduced during the previous session, she seemed to benefit from the use of visual supports (a form that could be filled in, and steps written on a white board) and the clinician’s verbal prompts. Throughout the session, LLL’s functional understanding of the strategy seemed to increase from having the opportunity to restate descriptions of each of the steps in her own words. By the end of the session, LLL was able to apply all three steps of the strategy to hypothetical situations through the use of diminishing cues and mass practice. While LLL had difficulty independently determining in which situations she could use the strategy outside the clinic, she responded well to the clinician’s direct instruction and agreed to use the strategy when riding in the car to and from the clinic this week.

37. Red- client responseBlue – reasons for client’s performanceGreen – plan for the future • A: Though LLL could not initially recall the order and Step One of the strategy introduced during the previous session, she seemed to benefit from the use of visual supports (a form that could be filled in, and steps written on a white board) and the clinician’s verbal prompts. Throughout the session, LLL’s functional understanding of the strategy seemed to increase from having the opportunity to restate descriptions of each of the steps in her own words. By the end of the session, LLL was able to apply all three steps of the strategy to hypothetical situations through the use of diminishing cues and mass practice. While LLL had difficulty independently determining in which situations she could use the strategy outside the clinic, she responded well to the clinician’s direct instruction andagreed to use the strategy when riding in the car to and from the clinic this week.

38. A: Based on a rating of at least 4 on PPP’s homework assignments, it was to be concluded that she can accurately follow complex instructions, write concisely, and alternate attention in a functional setting. However, because she was unclear about the “Writing Concisely” rating scale, more data should be obtained. Based on the results of the BRIEF-A, PPP does not demonstrate clinically significant deficits in executive functioning. Considering her performance on assessments, on therapy tasks in the clinic, and on homework tasks, PPP may not benefit from further speech and language services, and dismissal should be considered.

39. Red- client responseBlue – reasons for client’s performanceGreen – plan for the future • A: Based on a rating of at least 4 on PPP’s homework assignments, it was to be concluded that she can accurately follow complex instructions, write concisely, and alternate attention in a functional setting. However, because she was unclear about the “Writing Concisely” rating scale, more data should be obtained. Based on the results of the BRIEF-A, PPP does not demonstrate clinically significant deficits in executive functioning. Considering her performance on assessments, on therapy tasks in the clinic, and on homework tasks, PPP may not benefit from further speech and language services, and dismissal should be considered.

40. A: SSS continued to demonstrate increased self-efficacy during today’s session. She effectively restated the strategies in her own words and used analogies to describe them (e.g. “The steps are like my self-itinerary.”) Statements like these, as well as her increased use of the strategy tracking chart throughout the week, represent SSS’s increased understanding and ability to generalize the strategy to functional situations. SSS also identified that “breathing” (step 2) and “choosing a focus” (step 3) are “controllers” that she can “apply to triggers” when feeling overwhelmed. While SSS had a high level of independent success when applying her strategy to clinician-generated situations, she had greater difficulty remembering to implement them while using APT-3 as a generalization task. This may be attributed to her previous experience with APT-3, in which she was focused on completing the task to the best of her ability, and not on the explicit use of metacognitive strategies. SSS endorsed the clinician’s recommendation of practicing her strategy outside of the clinic room in the upcoming sessions, stating that although it “scares” her, it would be “worth trying.”

41. Red- client responseBlue – reasons for client’s performanceGreen – plan for the future • A: SSS continued to demonstrate increased self-efficacy during today’s session. She effectively restated the strategies in her own words and used analogies to describe them (e.g. “The steps are like my self-itinerary.”) Statements like these, as well as her increased use of the strategy tracking chart throughout the week, represent SSS’s increased understanding and ability to generalize the strategy to functional situations. SSS also identified that “breathing” (step 2) and “choosing a focus” (step 3) are “controllers” that she can “apply to triggers” when feeling overwhelmed. While SSS had a high level of independent success when applying her strategy to clinician-generated situations, she had greater difficulty remembering to implement them while using APT-3 as a generalization task. This may be attributed to her previous experience with APT-3, in which she was focused on completing the task to the best of her ability, and not on the explicit use of metacognitive strategies. SSS endorsed the clinician’s recommendation of practicing her strategy outside of the clinic room in the upcoming sessions, stating that although it “scares” her, it would be “worth trying.”

42. A: MMM’s successful performance during each step of the visual schedule indicates that he is capable of using an aid of this type. It will be helpful for the clinician to select one keyword (e.g. “finished”) to use as a verbal prompt during subsequent training of the visual schedule. MMM’s performance on the memory book activity suggests that it may be beneficial to focus on how to use the book, rather than focusing on his knowledge of the book itself (e.g. name, purpose). Altering the steps to include more functional ways to use the book during conversations (e.g. how to comment and ask questions about the topics) will be necessary for MMM to use the book during everyday life.

43. Red- client responseBlue – reasons for client’s performanceGreen – plan for the future • A: MMM’s successful performance during each step of the visual schedule indicates that he is capable of using an aid of this type. It will be helpful for the clinician to select one keyword (e.g. “finished”) to use as a verbal prompt during subsequent training of the visual schedule. MMM’s performance on the memory book activity suggests that it may be beneficial to focus on how to use the book, rather than focusing on his knowledge of the book itself (e.g. name, purpose). Altering the steps to include more functional ways to use the book during conversations (e.g. how to comment and ask questions about the topics) will be necessary for MMM to use the book during everyday life.

44. P: Section

45. P: Section

46. Example • S: John arrived on time to the therapy session… • O: (data table about objective performance in session, using comprehension questions and score at decoding individual words) • A: Comments on performance on data and client’s ease of reading content words compared to function words. • P: (1) Continue with comprehension intervention • (2) Create function word goals • (3) Immediate feedback of pragmatic deficits in group discussion

47. Main Points A good SOAP should be CUT: • Complete • Unambiguous • Truthful CUT out anything unnecessary S: section – CAP: • Clarify any ambiguities • Attribute statements correctly • Put our minds at ease In the A: section, include CREW: • Client response • Reasons/explanations • What to change Documentation is important!