Documentation may be an inescapable part of the job, but we are here to make it as efficient and painless as possible!
In this article, we’ll cover how to write a SOAP note for your adult speech therapy patients.
You’ll learn exactly what major funding sources (health insurance companies and U.S. Medicare Part B) look for in a note. You’ll also find plenty of speech therapy SOAP note examples and a free PDF checklist!
While this article outlines the fundamentals of a session note, your employer and funding sources may have their own guidelines for documentation. Be sure to follow them!
For pre-made documentation templates and (many more materials to make your job easier!) visit our shop.
More Popular Posts
- Why Do We Write Notes, Anyway?
- What Should A SOAP Note Look Like?
- 9 Elements of A Speech Therapy SOAP Note
- 1. Date of Treatment Session
- 2. Total Treatment Time
- 3. Each Intervention You Provided & Billed For
- 4. Patient's Response to Treatment
- 5. Cues You Provided
- 6. Ongoing Assessment Of Progress Toward Goals
- 7. Coordination with Care Team
- 9. Therapist's Signature & Credentials
- Free PDF! Speech Therapy Note Checklist
- More Adult Speech Therapy Materials
Why Do We Write Notes, Anyway?
1. To Assess Patient Progress Over Time
Documentation tells the story of a patient’s healthcare journey.
It began with a presenting illness, then came the speech therapy referral, and now speech treatment, where you come in.
Your SOAP notes continue the story. Which interventions worked over the days, weeks, or months? How did the patient respond? Did they meet their goals?
Most funding sources rely on your notes to decide if skilled speech therapy is worth paying for. This brings us to the second purpose of your note.
2. To Justify Your Skilled Therapy Services
Your note should:
- Prove that your patient needed skilled speech therapy
- Clearly spell out the skilled services you provided and why your patient needed them
- Justify any CPT codes you billed for. The interventions you document should match the codes you bill for that session
Example Of Unskilled Treatment
“Treatment included conversation practice.”
A funding source may conclude that they don’t need to pay you for conversation practice—this is something that a layperson could do with the patient.
Example of Skilled Treatment
“Therapist provided phrase-level expressive language treatment by having patient pair nouns with appropriate adjectives using prepared notecards.”
This skilled intervention shows that you have the specialized skills the patient needs to address their areas of need.
3) To Stay Focused On The Plan Of Care
Writing notes can help you to become a better practitioner.
They can remind you what you need to focus on, help you understand what works for your patient, what doesn’t, and how to improve your plan each session.
What Should A SOAP Note Look Like?
Every company’s speech therapy notes will look different.
Payers, including U.S. Medicare Part B and insurance companies, generally don’t care what format your note is in—as long as you include all of the elements they require.
To give you peace of mind, we consulted with an insurance specialist who confirmed that you don’t need to separate the S, O, A, and P or put them in any particular order. Just include all of the essential elements.
Below, you’ll find these 9 essential elements of a speech therapy note. They include all elements of a traditional SOAP note but are organized in a more logical (and insurance-friendly!) way.
To make your life easier, we also created a printable Treatment Note Checklist!
9 Elements of A Speech Therapy SOAP Note
1. Date of Treatment Session
Don’t forget to include the date of your assessment!
2. Total Treatment Time
Know your funding sources’ guidelines for documenting treatment time. If they don’t have guidelines, consider documenting total treatment time.
3. Each Intervention You Provided & Billed For
Describe how you implemented the patient’s plan of care. To do this, focus on the patient’s goals.
- List the therapeutic tasks and activities you did with the patient to work toward their goals
- Briefly describe the tasks and activities, if appropriate. See examples below
- Be clear how each task/activity relates to their goals
- Include any patient or caregiver training that you provided
- These tasks and activities should match the codes you billed
Speech Therapy SOAP Note Examples: Intervention
- The therapist provided patient with 6 oz of thin liquids, training in use of safe swallowing strategies (including chin tuck and bolus hold), then had patient take small cup sips of the thin liquid using the safe swallowing strategies.
- Therapist prepared a list of 50 /h/ initial words then reviewed voice strategies (including easy onsets). Patient practiced these voices strategies while reading the word list.
- Therapist provided phrase-level expressive language treatment by having patient pair nouns with appropriate adjectives using prepared notecards.
4. Patient’s Response to Treatment
Document how the patient performed on the interventions you provided. This is often measured by accuracy or completion.
- Include objective data and consistent measurements
- For example, if you use percentage correct to measure progress towards a goal, always use percentage correct when working on that goal
- Include patient or caregiver reports of patient progress toward their goals
- Patient states that she remembered to take her medications 3 days this week
- Be clear about why the patient needs continued speech therapy
- Patient continues to demonstrate signs and symptoms of aspiration in 20% of trials and requires moderate assistance to utilize swallowing strategies
Speech Therapy SOAP Note Examples: Patient’s Response
- The patient drank 4 ounces of thin liquids sans overt s/sx of aspiration (e.g., coughing, wet vocal quality, etc.) in 80% of trials (8/10 sips). The patient accurately used safe swallowing strategies in 90% of opportunities (9/10 sips).
- The patient completed a phrase-level expressive language treatment task at 80% accuracy (4/5 trials).
- The patient used easy onsets in /h/ initial words at 84% accuracy (42/50 words). They reported using easy onsets about 50% of the time during conversational speech with spouse.
5. Cues You Provided
Again, make it clear how each treatment required a skilled speech-language pathology professional present (versus a home exercise program). What specific skills did you provide for your patient? For example:
- Tactile cueing to lip
- Visual modeling of mouth postures
- Skilled tactile verbal training, etc.
Here’s what to include when documenting cueing:
Types of cues you provided:
- Written, etc.
How much cueing you provided:
How often you provided cueing:
- Frequent, etc.
Speech Therapy SOAP Note Examples: Cueing
- The patient drank 4 ounces of thin liquids sans overt s/sx of aspiration (e.g., coughing, wet vocal quality, etc.) in 80% of trials (8/10 sips). They accurately used safe swallowing strategies in 90% of opportunities (9/10 sips) given frequent minimal verbal cues and frequent visual cues (SLP modeled chin tuck, prompting, “Chin to chest”).
- The patient completed a phrase-level expressive language treatment task at 80% accuracy (4/5 trials) given frequent moderate verbal cues.
- The patient used easy onsets in /h/ initial words at 84% accuracy (42/50 words) given intermittent visual cues (SLP modeled large mouth opening and relaxed posture).
6. Ongoing Assessment Of Progress Toward Goals
Summarize the patient’s progress toward their goals.
When relevant, include other patient factors that impact progress toward their goals:
- Patient’s emotional response to treatment
- Change in impairment
- Environmental influences
- Family support
- Caregiver schedule
- Sleep schedule, etc.
Speech Therapy SOAP Note Examples: Ongoing Assessment
- Patient’s accuracy has steadily improved over the past 3 sessions. They will likely reach their goal by next week.
- Patient’s accuracy appears to be negatively impacted by fatigue related to dialysis. Recommend scheduling ST before dialysis or after the patient naps.
7. Coordination with Care Team
Include any relevant coordination with the care team that you haven’t already noted.
- Communication with the patient’s family or caregiver
- Communication or consultations with other disciplines (nursing, OT, PT, etc.)
- Outside referrals (nutritionist, otolaryngologist, neurologist, etc.)
Speech Therapy SOAP Note Examples: Coordination with Care Team
- SLP called and spoke with patient’s primary caregiver (daughter named Mei) and discussed progress and plan of care. Mei verbalized understanding and agreement to plan.
- SLP left message with primary care provider to request status of order for modified barium swallowing study.
8. Plan of Care
Write a short description of the next session’s plan.
- The tasks and activities you plan to use next session
- “Continue plan of care” is NOT specific enough.
- Why your patient still needs your skilled intervention
- Describe any changes to the plan of care and why
Speech Therapy SOAP Note Examples: Plan of Care
- Recommend continued dysphagia treatment with trials of thin liquids given the use of safe swallowing strategies.
- Next session: Continue phrase-level expressive language tasks using notecards with nouns/adjectives to address continued expressive language deficit.
- Continue practicing easy onsets with /h/ initial words. Trial /h/ initial multisyllabic words.
9. Therapist’s Signature & Credentials
Give yourself some credit! If signing by hand, make sure that your credentials are legible.
Free PDF! Speech Therapy Note Checklist
Below is your free speech therapy session note checklist PDF!
More Adult Speech Therapy Materials
For pre-made Documentation Templates and much more, check out The Adult Speech Therapy Starter Pack!
- American Speech-Language-Hearing Association. (2021). Documentation in Health Care. Retrieved September 13, 2021, from www.asha.org/Practice-Portal/Professional-Issues/Documentation-in-Health-Care/
- American Speech-Language-Hearing Association. (2021). Examples of Documentation of Skilled and Unskilled Care for Medicare Beneficiaries. Retrieved September 13, 2021, from https://www.asha.org/practice/reimbursement/medicare/examples-of-documentation-of-skilledand-unskilled-care-for-medicare-beneficiaries/#skilled-unskilled
- Gawenda, R. (n.d.) Documentation: Everything After the Evaluation Until Discharge. [Online lecture]. MedBridge Education. https://www.medbridgeeducation.com/courses/details/documentationeverything-after-evaluation-until-discharge-rick-gawenda
- Gawenda, R. (n.d.). Documentation for Evaluations and Re-Evaluations [Online lecture]. MedBridge Education. https://www.medbridgeeducation.com/courses/details/documentation-evaluations-reevaluations-rick-gawenda
- Medical Learning Network, The. (2019). Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements [PDF file]. Retrieved on September 13, 2021, from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/OutptRehabTherapy-Booklet-MLN905365.pdf