SOAP notes
S Subjective Information
-Client story
-Client feeling
Kirk was noncompliant with therapy activities today. He
frequently replied “No” when asked
to participate and required cuing to
remain in his seat
-Symptoms described (severity,location,duration,frequency)
-Client report recent improvements
-Client report past medical/social history
-Clients family info
Mr. Lee was in a
pleasant mood during therapy today,
although he stated that he was
a little tired. His wife stated, “He
didn’t sleep well last night,” and he
reported difficulty concentrating dur
ing the session
-Client stated, “…”
O Objective Information
Goal of session (maybe more than 1)
ShortTerm Goal 2: The client will
reduce disfluencies to less than 20%
during a 3 minute conversation with
a familiar person in the therapy room
within six sessions.
Result of observation
Result of Data report
Data: 9/10 = 90% (words) no cues
6/10 = 60% (phrases) no cues
6/10 = 60% (sentences) with
verbal cue reminder to use con
trolled rate
*Objective, unbiased, accurate
A Analysis
*Not to report assessment result data but analyse**
-Clinical reasoning:
Compare to previous sessions- what improved/decreased-
specific (why)
Difficulties remained/New difficulties (why)
Criteria met or not
Does cue help/increased?
-Action done
-Cuing/ stimulus given
-Advice given
Mr. Lee’s accuracy
was decreased by 40% from previ
ous sessions, likely due to reported
fatigue and difficulty concentrating.
Repeating the stimulus and a verbal
cue reminding him to “chunk the
information” increased his accuracy
significantly.
P Plan
Goal continue or modify
Any homework
Any cue (modify) ,reinforcement and stimuli
Interventions planned ahead
Timeframes for review and recovery
Correspond to who and referred to who
Alternative communications
The level for /s/ initial
should be increased to spontaneous
phrases due to Cowan consistently
meeting criteria. A probe list will be
used to assess generalization for other
positions. Cues will be restructured
based on goal modification. Reinforce
ment with stickers will be continued
due to Cowan’s increased motivation.
Case Example=
Case SOAP
The client attended their first session last S: Client attended initial session. Daughter
week. reports recent memory concerns.
Although the referral lacked specific
medical details, O: Mild speech difficulties observed during
there is a possible history of stroke or head session. Medical history limited; possible
injury. prior stroke or head injury reported.
During the session, the client demonstrated
mild A: Further assessment indicated to
speech difficulties, and their daughter characterize speech and cognitive-linguistic
reported recent profile and determine severity and impact.
memory concerns. Further assessment is
needed to P: Plan to conduct comprehensive speech
determine the nature and extent of the and language evaluation, including
difficulties cognitive-linguistic screening; gather
detailed medical history.
I saw Mr Carey at bedside today. He opened S: Patient seen at bedside today.
his eyes and attended
when touched but did to response to any of O: Eyes opened and attended to tactile
my verbal request. stimuli; no response to verbal requests.
Assessment of speech, language, and
cognition awaits improved A: Speech, language, and cognitive
alertness and responsiveness. I will see his assessment deferred pending improved
at his bedside daily to alertness and responsiveness.
monitor his progress and will schedule more
extensive testing when his
alertness and responsiveness permits. I will P: Continue daily bedside monitoring of
also cross reference it with alertness and responsiveness. Plan
an entry in the Doctor’s Orders. comprehensive evaluation when patient’s
condition permits. Cross-reference with
Doctor’s Orders.
SOAP Examples
Name: Genevieve Tan Date:
Client’s Initials: Frankie Age: 21 months
Communication Disorder: Expressive language delay
This session focused on completing the Rossetti Infant-Toddler Language Scale, building on
the groundwork laid in the previous session. With the return of the parent questionnaire, the
student clinician was able to fill in gaps and finalise the assessment. The process was
smoother than before thanks to prior data collection and the helpful involvement of educators,
who facilitated meaningful opportunities for Frankie to engage and respond.
Frankie presented as cheerful and socially engaged, immediately welcoming the student
clinician with a smile and a gesture to sit beside her. Her educators noted a marked change in
mood, explaining that she had been feeling unwell in recent days, which had affected her
openness to interaction.
Through communicative temptations, the student clinician elicited speech in spontaneous and
purposeful ways. When prompted to ask for “more”, Frankie successfully verbalised the
word. Over the course of play, “more” was clearly and independently repeated 16 times.
Similarly, she was encouraged to say “please” when requesting help opening a door, and this
word was subsequently used with intent.
Frankie showed increased use of verbalisation and imitation compared to previous sessions,
with reduced reliance on jargon and gestures. She responded accurately to size-based
questions (e.g., identifying shoes for herself versus the clinician) using both verbal cues and
gestures. Her emerging use of the word “yes” [jer] was noted 13 times in contextually
appropriate moments with educators.
Social observations also revealed her developing sense of responsibility in the classroom—
distributing drinks to peers and comforting a younger child—highlighting an evolving role as
a “big sister” figure.
Assessment using the Rossetti suggests Frankie is ahead of her age range in play and
language comprehension (27–30 months) and gestures (24–27 months). Pragmatics and
motor skills appear age appropriate. Expressive language presents a mixed picture: while the
Rossetti indicates age-appropriate behaviours, observed inconsistencies—including lack of
spontaneous singing (noted by both parent and clinician)—suggest the need for further
investigation.
To gain a clearer understanding of Frankie’s expressive language development, the student
clinician plans to administer the PLS-5 (Preschool Language Scale–5) and continue direct
observation. The goal is to triangulate findings from formal assessments, educator feedback,
parental input, and naturalistic observations to develop a well-rounded developmental [Link] Client Note
Example:
MP attended a follow-up session for voice therapy and reported experiencing fluctuations in
voice quality—some days are “good” with no croakiness, and others are “bad” with
noticeable croaky voice. On this particular day, he described his voice as being in good
condition. During the session, the clinician noted that MP had a significant amount of phlegm
and needed to clear his throat frequently.
MP shared that he’s been consistently practicing Resonant Voice Therapy (RVT), Semi-
Occluded Vocal Tract exercises (SOVT), and abdominal breathing at home. When reviewing
these techniques, MP demonstrated a solid understanding of abdominal breathing and was
able to feel his diaphragm move during the exercises. Combining RVT with abdominal
breathing, he could perform humming tasks but had difficulty producing words clearly, with
moderate strain and roughness still present.
During the SOVT review, MP showed proficiency in replicating the clinician’s model. The
accent method was introduced to enhance his vocal function, but he found it challenging to
produce ascending “woo” sounds. Encouragingly, using SOVT as a bridging technique
helped MP improve his RVT hum at the word level with less strain and roughness.
Considering MP's history of voice changes following surgery, along with reflux, asthma, and
a chronic cough, his vocal quality is likely affected by an organic voice disorder. The
clinician observed moderate strain and roughness throughout the session.
To support his continued progress, MP was provided with a personalized home care voice
therapy program. He has now been discharged from regular sessions but is welcome to return
for follow-up support if needed
ISBRA Notes
I Identify= client information
S Situation= reason for referral, diagnosis, reason
B Background=
Social history
Medical history
Observations
Third Party Report
A Assessment and results interpretation
R Recommendation
-rationale
-additional assessment
-referral