SOAP NOTE
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Date: 17 June 2024
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Time In: 11:00 AM Time Out: 11:00 AM |
Direct: ☒ Indirect: ☐ |
Consult: ☒ No Session: ☐ |
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S |
O |
A |
P |
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☒ |
Alert |
Goal(s) and Objectives: The therapy session is aimed at improving expressive language and articulation. |
Prompts |
☐ |
Baseline |
☒ |
Continue Objective |
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☒ |
Cooperative |
NOTES: Therapeutic Interventions:
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☒ |
Indep |
☒ |
Verbal |
☐ |
Mastered |
☐ |
Objective Met |
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|
☐ |
Sick |
☐ |
Minimal |
☒ |
Visual |
☒ |
Almost mastered |
☐ |
Initiate New Objective |
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|
☐ |
Uncooperative |
☒ |
Moderate |
☐ |
Gestural |
☐ |
Making progress |
☐ |
Discontinue Objective |
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|
☐ |
Tired |
☐ |
Maximum |
☐ |
Touch |
☐ |
No Change |
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Other: Responsive, active |
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☒ |
Physical |
☐ |
Regression |
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Notes: The client was alert and responsive to the prompts. She has made noticeable progress in her expressive language skills. The client was able to correctly articulate /s/ and /r/ sounds in single words and simple sentences with 70% accuracy, successfully completing 8 out of 10 tasks. The plan is to continue focusing on expressive language and articulation. In the next session there will be an introduction to more complex sentence structures and new vocabulary words. The client is steadily advancing towards her therapy goals.
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