Exam 1- Soap Notes

Question 1

What are SOAP notes?

Answer 1

Brief, informative notes that focus on what others need to know about your sessions.

• Include whatever an insurance company would need to see in order to justify your continued involvement with the patient.

Question 2

What does “SOAP” stand for?

Answer 2

S = Subjective
O = Objective
A = Assessment
P = Plan

Question 3

S = Subjective

Answer 3

• Describe your impressions of the client. Include client’s level of awareness, motivation, mood, willingness to participate, etc…
• Also list anything the client and/or family may say to you during a session.

E.g., “G.W. appeared alert and cooperative. He stated, “I’m ready to work hard today.”

Question 4

O = Objective

Answer 4

• Write MEASURABLE quantitative information; your data.

- Test scores and percentages for any objectives worked on.

Question 5

A = Assessment

Answer 5

• Describe your analysis of the session
• *The interpretation section
• Compare the client’s performance across sessions

Question 6

P = Plan

Answer 6

• Outline the course of treatment.
• Include any changes to objectives, activities, or reinforcement schedules.

E.g.,

a) Continue current treatment activities.
b) Continue training production of functional CVC words at the phrase level.