How To Write Professional-Sounding SOAP notes
- Write exactly what happened was objectively as possible.
- Don’t use terminology that a parent / insurance company won’t understand.
- Use third person
- Use formal speech, no slang
Formula:
S: Subjective description of the student’s mood, behavior, etc. This is your opinion of the student during the session.
O: Objective data about how the student performed on goals during the session.
A: Assessment and interpretation on how the student performed on skills along with comparison to previous data.
P: Plan for future therapy sessions or homework.
Example:
S: Student was cooperative and compliant throughout the session though he was having more difficulty maintaining attention by the end of the lesson.
O: Student produced /k/ in the initial position of single words with 62% accuracy. Student used the pronouns “he” and “she” correctly when answering questions about a book with 72% accuracy.
A: Student increased accuracy on /k/ initial from 58% to 62% accuracy since the last session and decreased accuracy on the pronouns “he” and “she” from 86% accuracy to 72% accuracy. Student was having trouble maintaining attention during the book-reading activity which could have led to decreased accuracy.
P: Will continue as planned for /k/ initial. Parents will work on /k/ initial words for homework. During the next session, the book reading activity will be placed at the beginning of the session to see if accuracy improves.
