example soap notes speech therapy

Journal for Practice Managers

• All Articles
• Case Studies

How to Write Speech Therapy SOAP Notes (with Examples)

According to the statistics , there are around 13,000 practising SLPs in the UK and around 2.5 million people in the UK have a speech or language difficulty:

• 5% of children enter school with difficulties in speech and language
• 30% of people who have had a stroke have a persisting speech and language disorder.

In terms of the functional duties of a speech therapist, we can single out one very significant duty that should not be overlooked. This is the completion of the necessary documentation in the prescribed form to meet the demands of a huge number of these people. A clinician's ability to manage it is one of the most important indicators of their professionalism.

A therapist devotes a lot of time to writing session notes, conclusions, characteristics, representations, and the design of speech cards. Thus, he should use his working time rationally.

Medesk helps to automate record keeping and recreate an individual approach to each patient, paying maximum attention to him.

When identifying children with peculiarities not only regarding speech development, he makes suggestions for further successful plan of care, or, if necessary, refers them to a specialist (neuropsychiatrist, neuropathologist, otolaryngologist, etc.).

Therefore, in order to save more time on the selection of the necessary phrases, special expressions, and formulations, we have selected a few suggestions for daily notes that simplify filling out the documents, while maintaining their content and accuracy. As a result, they are better able to organize their work and develop their skills in the field of speech-language pathology.

A SOAP note format is one of the most effective ways to fill out a progress note. We are planning to teach you how to use this tool in your private practice. In addition, we are going to give you some lifehacks and tips that will make the client's progress a reality.

SOAP Note Format for Speech Therapy Sessions: What is It?

SOAP notes are widely used by various specialists: mental health professionals , psychologists, caregivers, and speech-language pathologists.

When filling out a document for clients, it is necessary to know the content of regulatory documents related to this issue. It is also necessary to remember the age and individual characteristics of the person based on his diagnostic data, and take into account the results of speech development.

This information is included in the soap note template.

#1. S is for Subjective

The subjective section contains information about the actual state of the patient. Ideally, this part of the notes should be as true to life as possible. What does it mean?

The doctor keeps track of the complaints and speech issues of the patient, as well as other significant information about the patient. He must report only the words of the clients, but not his own thoughts and ideas. It’s not the time for it.

The first priority is to take stock of symptoms and make up a potential and theoretical treatment plan (but not to put it down). Try to use direct speech.

More frequently, the clients of speech pathologists are children, accompanied by their parents. So, sometimes you listen to both of them.

For example, you can mention:

• Mrs. Smith (Billy’s mother) claims that the child has speech development problems.
• "The child suffered pneumonia at an early age."
• The mother claims that the child prefers to work with his left hand.
• "I find it difficult to come up with a word for a given sound."
• "Billy has been stuttering since he was 3 years old."
• "He is inconsiderate and impulsive."

#2. O is for Objective

The objective section of the notes contains your thoughts, prognoses and conclusions as a professional. The name of the section makes it pretty obvious. Test results, questionnaires, physical examination, fine and gross motor skills, articulation and tempo, speech intelligibility, breathing characteristics, and any other measurable indicators should be included in this section.

You can also provide some additional information (brief – psychological and pedagogical characteristics), if applicable.

The main rule is to avoid value judgments and be completely unbiased.

In the table below you’ll find different aspects to include in the objective part of a treatment note and some examples of possible answers.

#3. A is for Assessment

The assessment section summarizes the achievements of two previous sections. Note-taking at this stage includes analysis of subjective and objective information and interpretation of the whole session.

Now you are finally free to use professional terms and acronyms, as this part of the notes is for professional use only. And if you aren’t able to continue the therapy, a substitute therapist will easily know what to do thanks to your notes from the last session.

At Medesk, information about each patient is stored in an individual electronic medical record. It allows you to view all the services rendered to him during the treatment at the clinic. The attending physician can get acquainted with the patient's medical history, view all the appointments and reports that were written by other doctors, as well as compare the results of current and previous analyses of the patient.

It should be noted that there is no need to repeat the S and O sections. And also, it’s a bit early to make plans - just wait for the next stage and follow the SOAP structure.

As an example, we give you some assessments of the difficulties of educational material’s assimilation (a child in a primary school):

• Difficulties of adaptation in a school institution;
• Violation of motor skills in the form of insufficient coordination of movements;
• Pedagogical neglect due to unfavorable social conditions of the child;
• Disadvantages of attention, emotional-volitional regulation, self-control;
• Motor disinhibition, hyperactivity;
• Verbal and logical thinking is poorly developed;
• Insufficient development of coherent speech;
• Neurotic and neurosis-like states (fears, tics, mild stuttering, enuresis, etc.)

#4. P is for Planning

The last stage of note-taking is creating future plans for treatment. The plan section contains goals and recommendations for the follow-ups, even some handouts, since the plan is for a client and other healthcare professionals, who will take part in his treatment.

When writing any kind of counseling notes , set goals in the final section and make sure they are realistic and measurable. It's vital for a patient to remain motivated and to believe in recovery. You can easily split the goals into small ones to make a client’s performance and progress more transparent.

Moreover, the plan makes arranging individual sessions easier. Therefore, as a professional who wishes to get the greatest profit for given help, you increase your chances of setting up the next session.

As a bonus, we’ve collected some recommendations you can include in the plan stage:

• Avoid intellectual and psychological stress;
• The child needs an individual approach and constant supervision by adults;
• In order to compensate and equalize the shortcomings of physical, mental and speech development, avoiding overloads, it is recommended to repeat the course of study (or study in a special correctional school);
• It is recommended to consult with specialists...
• Additional rest is recommended;
• Conducting an additional examination in order to determine the child's need for further education, taking into account his level of development;
• The child needs step-by-step guidance and frequent changes in activities;
• Continuation of speech therapy classes according to the schedule 2-3 times a week for 45 minutes;
• Attending a special (correctional) school;
• Classes with parents aimed at developing motor functions, designing, classifying, viewing pictures, reading fairy tales, playing the story; plot-role-playing games; fixing the use of gestures for communication; development of auditory perception (differentiation of sounding toys, sounding pictures in books), onomatopoeia.

Electronic SOAP Note Example

The SOAP format of making notes has proven itself as a convenient, simple, but effective technique.

But do you remember that you should make notes during every session?

Though filling four sections of a note is rather simple, it takes a lot of time and strength to do it manually.

For professionals with a large patient flow (and we are sure, you belong to this category), the use of Electronic Health Records is a must.

The benefits of the software are obvious:

• All necessary stages of your future notes are pre-set for you (with templates ready to be printed)
• You can use an autofill option for the most general data
• The interface is easy and makes it possible to fill out the information right during the session with minimal distractions for the patient.
• It's unreal that the notes have been lost. All data is securely stored.

A good SOAP note is the result of the thorough work of a speech specialist. But you can make your practice much easier by implementing EHR in your therapy service.

Join our team of more than ten thousand happy practitioners!

Should You Charge Your Patient’s a No-Show Fee? Pros & Cons

6 top medical practice management software for your practice in 2024, how to start a physical therapy clinic in 2024 [10 easy steps].

• Online Booking
• Electronic Health Records
• Consultation Form Templates
• Integration
• Task Management
• About Company

[email protected]

social media

404 Not found

Practice Management Blog

Productivity & Mindset

Guide: SOAP Notes for Speech Therapy

As a speech pathologist , it’s important that your SOAP notes are well-structured, accurate, comprehensive, and helpful for both you and your client. This helps ensure that clients receive the best care possible, making your job easier. But when you’re juggling multiple responsibilities, note-taking can suffer. Fortunately, with the right approach, it’s possible to ensure that your SOAP notes are of the highest quality.

What Is a SOAP Note in Speech-Language Pathology?

SOAP notes are widely used for documenting the progress and treatment of clients in various healthcare fields, such as general practice, mental health , and speech therapy. SOAP notes provide a structured format to succinctly document a client’s information , such as reported symptoms and concerns, observations from the clinician, any measurable data, an assessment of the client’s condition, and a plan for treatment moving forward.

Your SOAP notes not only serve as a record of the client’s progress, but they also help to communicate important information to other healthcare team members. Whether you’re a seasoned speech therapist or just starting out, understanding how to write effective SOAP notes is essential to providing top-notch care to your clients.

Recommended SOAP Note Format for Speech Therapy Clinics

SOAP stands for S ubjective, O bjective, A ssessment and P lan. These four components of a SOAP note provide a framework for the documentation of speech therapy sessions. In the sections below, we’ll go into more detail about each element.

This section is all about what the client is experiencing. It should address client concerns, symptoms, and any other relevant information reported, including the history of treatment, current lifestyle, and any external factors affecting the client.

While this section may contain subjective observations of the client’s mood and demeanor, try to keep things as factual as possible. For example, rather than saying, “The client seemed anxious.” you could say, “The client reported feeling anxious.”. You should also record any medications the client is currently taking.

When writing the objective section of a SOAP note, you should document any measurable or observable information you’ve gathered during your assessment. This includes data such as physical examination findings, vocal range articulation and vocal quality. Record the results here if you perform tests such as a standardized assessment, an audiogram or a hearing test.

This part of your SOAP note should include a summary of your observations and an analysis of the client’s condition. If you come to any conclusions or diagnoses, make sure to include these. This section should be detailed and provide a clear framework for the rest of your note.

Finally, the plan section will include your proposed treatment plan. This could involve regular therapy sessions, advice on lifestyle changes, recommended exercises or any other interventions you deem necessary. Also include how you’ll review the client’s progress, and what goals you have for them to achieve.

How to Write SOAP Notes for Speech Therapy

Here are a few handy tips to help you get started:

Use a SOAP Note Template

Using a template for SOAP notes can help you write clear and consistent notes, saving time by allowing you to fill in the necessary information quickly. By using the same template for all your notes, you can ensure that each note contains the necessary information and is easy to read.

A template also helps to keep your notes cohesive. This provides a consistent structure for all of your SOAP notes, making them easier for other team members to follow and understand.

Be Overly Descriptive

You might be tempted to shorten and quickly sum up your notes to save time – don’t do it! It’s crucial to be detailed and descriptive when writing SOAP notes for speech pathology. It will help you provide a comprehensive overview of the client’s progress.

It’s better to over-explain than to under-explain. Your notes should include any goals set in the session, any interventions used, the date and time of any events, and a detailed record of any observations made during the session.

Write SOAP Notes Immediately Following a Session

It’s strongly recommended that you develop SOAP notes immediately after the speech therapy session. Recalling details is much easier when events are still fresh in your mind. If you wait too long to write up the notes, details may become distorted or forgotten, leading to misunderstandings and inaccurate records.

Make Notes Easy to Understand

Having legible notes ensures that third parties can understand and interpret information. Avoid any kind of shorthand or obscure abbreviations when writing SOAP notes for speech therapy.

Arrange your notes logically and chronologically and separate each section clearly. This improves the readability of your notes and makes it easier for others to understand the information. It’s possible that third parties may need to use your notes for diagnostic purposes or accommodations, so they must be accessible.

Use Direct Quotes

If possible, use direct quotes to illustrate client progress. For example, if the client was able to say a particular word for the first time during their speech therapy session, you could use a direct quote to note this. Doing so provides a more accurate and vivid representation of what occurred during the session. It’s also a useful way of recording client symptoms and progress objectively.

Include Measurable Data

Where possible, include measurable data to give a more accurate report of the client’s progress. For example, if you notice that they’re able to pronounce a certain phrase correctly, note the number of times they could say it in your notes. This provides an objective measure of client progress, which can be used to inform future interventions.

Compare Progress to Previous Sections

Comparing the client’s progress to performance in previous sessions can be illuminating. It allows you to see how they’ve improved over time and any areas that may need additional work or intervention.

By pointing out this information to the client, you can help encourage and motivate them as they strive towards their goals. You can also use this data to adjust the plan of action to better support the client’s needs. It’s a powerful way of demonstrating their progress and provides a sense of accomplishment.

Do a Double-Check

Last, but not least, it’s essential to double-check SOAP notes before submitting them. Some insurance providers may reject reimbursement claims if any sections are missing, so check for gaps or inconsistencies. Even the most experienced clinician can make mistakes (especially when managing a busy caseload), so take the time to review your notes for accuracy and completeness.

Questions to Answer with Your Speech Therapy SOAP Notes

A helpful way of framing your SOAP notes for speech therapy is to ask yourself what information you’d hope to gain by reading someone else’s notes. You can even run through a checklist of questions to ensure you include relevant information.

Here are a few questions to consider when writing SOAP notes:

• What are the client’s goals?
• In what areas is the client progressing?
• In what areas does the client need improvement?
• Is the client ready to finish speech therapy services?
• How was the client’s attitude and behaviour?
• Should any changes be made to their treatment plan?
• What was the outcome of the session?

Asking yourself these questions helps ensure your SOAP notes provide a comprehensive overview of the client’s progress. This also helps to make sure that all relevant information is captured, which can be helpful for third parties that may need to access the notes.

Examples of SOAP Notes for Speech-Language Pathologists

Here are two fictional examples of SOAP notes for speech-language pathologists:

Example 1: Initial Evaluation SOAP Note

Subjective:.

• Client presented with concerns about difficulty speaking clearly and being understood by others.
• Client also mentioned feeling self-conscious about their speech and avoiding social situations because of it.
• Client demonstrated significant difficulty with articulation and phonological processes, including substitutions, omissions and distortions.
• Client also displayed moderate receptive language delays in understanding complex instructions.

Assessment:

• Based on initial evaluation data, the client is presenting with a severe speech disorder impacting their daily communication skills. Further assessment is needed to determine specific areas of need for treatment.
• Refer the client for further assessments, including formal speech and language evaluations.
• Begin therapy sessions to address speech sound disorders, incorporating evidence-based techniques such as motor-based approaches and phonological awareness activities.
• Provide education and resources for family members to support the client’s communication needs at home.

Example 2: Progress Note

• Client reports progress with speech therapy sessions and increased confidence in their verbal communication.
• Client demonstrated improved articulation skills, reducing the number of errors from 60% to 20%.
• Client also displayed improved expressive language abilities, using more complex sentence structures.
• Based on progress data, the client is showing significant improvements in both articulation and expressive language skills. Client’s self-esteem and confidence have also improved.
• Continue therapy sessions focused on speech sound disorders, incorporating activities to further improve articulation accuracy.
• Expand therapy goals to include increasing expressive language abilities and targeting specific communication situations identified by the client as challenging.
• Encourage continued practice of communication strategies in daily life.
• Provide resources for ongoing support and practice at home.
• Schedule a follow-up assessment in 2 months to monitor progress and adjust therapy goals as needed.

Benefits of Using Electronic Speech Therapy Notes

Using an electronic method of recording SOAP notes for speech therapy provides many benefits for busy clinicians:

• Time-efficient : Typing notes into a computer or tablet is much faster than handwriting each note. This can save significant time and energy during a session, allowing clinicians to spend more time engaging with their clients.
• Accurate and easy to read : Computer-generated text is much easier to read than handwriting, especially if multiple clinicians need to access the notes.
• Searchable : Electronic notes can easily be searched using keywords, saving time when revisiting previous notes or looking for certain topics. This makes it easier to access information quickly and efficiently.

By taking advantage of these features, clinicians can spend more time focusing on client progress and goals, and less time worrying about note-taking. Ultimately, this can help to improve the quality of care that clients receive.

Write SOAP Notes for Speech Therapy with Power Diary

Power Diary is a comprehensive client management and appointment booking solution that will help streamline your practice. Our intuitive user interface makes it easy to capture SOAP notes for speech therapy in an efficient and secure way.

Practice Management Software for SLPs

Practice management software transforms the daily grind for Speech-Language Pathologists into a smoother, more efficient process. The software’s ability to store detailed, accessible SOAP notes allows you to document client progress accurately and securely. This not only helps in tracking therapeutic outcomes but also provides a record for future reference, contributing to a more coordinated care approach. It’s like having a digital assistant that organizes schedules, keeps detailed client notes available when needed, and ensures everyone on the team is on the same page.

If you’re interested in learning more about Power Diary and how it can help you write SOAP notes for speech therapy, start a free trial today.

Most Popular

• Best Healthcare Podcasts
• How to Write a Great Referral Feedback Letter
• 5 Ways Your Practice Can Look More Professional
• Balance or Burnout
• The Ultimate Waiting Room Checklist

Power Diary Picks

• 7 Reasons Private Practice Owners Rock
• Is Perfectionism Costing Your Health Practice?
• How to Price Your Health Services
• Ideal Client Profile Blueprint
• Beginner's Guide to SMS Marketing for Your Clinic
• All Articles
• Compliance & Security
• Marketing & Growth
• Power Diary Updates
• Practice Management Tips
• Release Notes
• Reporting & Analytics

Share this on:

Related Articles

Topics to Discuss with a Therapy Mentor

Art Therapy Activities for Teens

SOAP Notes for Mental Health Counseling: Templates + 5 Tips

SOAP Notes For Speech Therapy Template

Functional SOAP note template for speech therapy, helping you to streamline your documentation and create compelling and accurate SOAP notes. 

By Alex King on May 15, 2024.

Fact Checked by RJ Gumban.

What is a speech therapy SOAP notes?

Within the confines of a private practice's therapy room, speech pathologists engage in the art of documenting client progress during speech therapy. After each session, they conscientiously write notes, translating subjective observations into objective data—a crucial aspect for future sessions. 

Witnessing patient progress firsthand, therapists find fulfillment in their skilled interventions. The records serve as guideposts, shaping the roadmap for individual sessions and marking tangible strides. This meticulous process measures progress and weaves a growth narrative for the treatment session. It creates a vital bridge connecting the previous session to the promising horizons of the next session.

Speech therapy SOAP notes  are a form of clinical documentation that speech therapists use in documenting speech therapy sessions and progress of their clients. As one of the most popular ways to organize progress notes, the SOAP format separates information into four sections:  subjective ,  objective ,  assessment , and  plan . These four sections cover different types of information:

• Subjective : The client's subjective description of their concern, including symptoms and how it affects their day-to-day life. This section often includes direct quotes from the client.
• Objective : Your professional observations about the client's behavior, the interventions you used during the session, and how the client responded. The objective section should also include any tests or assessments that the client completed.
• Assessment : A synthesis of the above sections; your assessment and analysis of the session. This section includes treatment goals and determines progress made by client.
• Plan : The final section outlines the future plan for the client, including any upcoming sessions, goals to be completed, or relevant changes to the treatment plan.

The speech therapy SOAP note template is both intuitive and coherent; it aims to simplify the note-taking process so you can save time without compromising the quality of your documentation. Using a SOAP note template is one of the best ways you can optimize the more administrative aspects of working as a speech therapist. By utilizing this resource, you will be able to save countless hours that can instead be spent treating more clients.

Printable SOAP Notes For Speech Therapy Template

Check out these therapy SOAP note templates to improve your progress notes, productivity, and therapy outcomes for skilled intervention.

Check out these therapy SOAP note templates to improve your progress notes, productivity, and therapy outcomes.

How to use this SOAP note template for speech language therapy 

Using the speech therapy SOAP note template is very easy. Regardless of whether you are an individual practitioner or work at a  speech therapy practice , we have designed this resource with the understanding that most speech therapists lead busy lives and as such, they are on the lookout for simple ways to speed up their documentation. With that in mind, here are four simple steps that can guide your usage of the template: 

Step 1: Download the template 

The first thing you need to do is click on the link that will take you to the PDF version of the template. From here, you will be able to edit the document where necessary. 

Step 2: Fill out the four sections 

After you have downloaded the SOAP note template, it's time to fill out the four sections (subjective, objective, assessment, and time). When you are writing your documentation, you want to be as clear and concise as possible, while also including every piece of relevant information based on the patient's response. 

Step 3: Don't forget credentials

Every speech therapy SOAP note needs to include certain credentials: your client's name (and ID number where applicable), the date/time of the session, and your own professional credentials. These details are useful when it comes to insurance and billing processes. 

Step 4: Store your SOAP note securely

In order to adhere to HIPAA compliance regulations, you need to store your SOAP notes securely. If you store it online, you need to ensure the platform has suitable electronic safeguards so your client's data is protected at all times.

SOAP Notes For Speech Therapy Template example (sample)

We have created the following sample to help you visualize what a completed speech therapy SOAP note might look like. The specific content of each SOAP note will differ depending on your session with each client, but this should give a good overview of the type of information you need to include and where it goes within the template. 

Here is an example of what the SOAP note template will look like once it has been properly filled out by a speech therapist:

Who can use this speech therapy template?

One of the best things about the  SOAP note template  we have used is how customizable it is to different fields of speech therapy. Essentially, this SOAP note template applies to any kind of speech therapist who has sessions with clients, including those who work as solo practitioners and those who work in group practices. 

Additionally, speech therapists often work with a range of clients who may all have different problems, disorders, or assessments, including the following: 

• Speech therapy for apraxia
• Speech therapy for aphasia 
• Speech therapy for stuttering
• Speech therapy for swallowing difficulty

Further, each of these types of speech therapy is applicable to clients of all ages. The specific methods that speech therapists use to treat these disorders may differ depending on their client's age, but the format for writing SOAP notes will remain the same. 

As you can see, the speech therapy SOAP note template is able to be used by pretty much every speech therapist, regardless of where they work or what type of therapy they specialize in!

Why is this template useful for speech therapists?

The most important use of a SOAP note template for  speech therapists  is how effectively it organizes clinical documentation. Writing accurate notes can be a time-consuming process, but with this template, you can streamline this process without reducing the overall quality of the note. Other uses include:

• Consistency : Writing consistent SOAP notes helps with readability. When you check your previous notes, you can extract relevant information faster if they are consistent, which is much easier if you use a SOAP note template. 
• Accuracy : The SOAP note template visually separates the four different sections. Using this template will ensure that you don't accidentally forget to fill out all four sections, helping to improve the overall accuracy of your documentation. 
• Suitability : As we mentioned, the SOAP note template has been designed to suit various types of speech therapy. This allows you to access an intuitive SOAP note template and use it for all of your clients, regardless of the differences in their specific speech problems.

Why use Carepatron for SLP SOAP notes?

Carepatron offers an all-in-one practice management software to greatly assist your  speech therapy practice  when writing SOAP notes. In addition to offering a range of different templates, Carepatron has useful voice-to-text transcription software.

With the recent rise in practice management systems, it can be not easy to find the perfect platform for your business. Nevertheless, we think Carepatron will be the solution you've been looking for. As well as offering clinical documentation tools, Carepatron is integrated with medical billing, coding, appointment scheduling, patient management, and workflow features designed to streamline your administrative processes.

With this all-in-one system, you will be guaranteed to optimize your productivity and save countless hours that can instead be spent doing what you do best: treating clients.

Commonly asked questions

This question doesn’t have a definitive answer, but as a good rule of thumb you should aim for 1-2 pages. You want your SOAP notes to be concise and clear, but without any repetitions.

Yes. SOAP notes are legal documents and every client has the right to access their progress notes. For this reason, it is absolutely essential that the information you include is objective, relevant, and truthful.

Yes, HIPAA has certain regulations that are applicable to SOAP notes. Firstly, HIPAA requires you to keep progress notes for each session with a client. The guidelines also require you to store these notes in a safe and secure way, so confidential information pertaining to your client is protected.

Related Templates

SOAP Notes For Acupuncture Template

Incorporate this acupuncture SOAP notes template into your practice to achieve higher-quality outcomes.

SOAP Notes for Massage Therapy Template

A SOAP note template for massage therapists looking to streamline their clinical documentation while improving accuracy and effectiveness.

SOAP Notes for Nurse Practitioner Template

Nursing SOAP Notes templates elevate the accuracy and quality of your clinical documentation.

SOAP Notes for Dental Template

A simple PDF dental SOAP Notes template designed for use by dentists, orthodontists, or dental nurses.

SOAP Notes For Physical Therapy Template

An intuitive SOAP note template for physical therapists will help your practice improve its documentation, all while saving valuable time.

SOAP Notes for Counseling Template

A fantastic PDF SOAP note template for counseling, helping you to simplify documentation and improve clinical outcomes for your patients.

SOAP Notes For Social Work Template

Social work SOAP note templates enhance the quality of your note-taking while streamlining your client workflows.

SOAP Notes for Mental Health Template

Mental Health SOAP note templates are an excellent way to promote consistency in your practice, enhance your note-taking, and make accurate assessments.

SOAP Notes For Psychiatry Template

A simple-to-use psychiatry SOAP notes template in an editable PDF format to help you improve communication, productivity, and clinical outcomes.

SOAP Notes for Therapy Template

SOAP notes are the best way for therapists to capture clients' mental health. With this template, you can effectively streamline notes and achieve higher clinical outcomes.

SOAP Notes Template

Elevate your clinical documentation, improving accuracy, productivity, communication, and clinical outcomes.

SOAP Notes For Occupational Therapy Template

A simple, downloadable PDF template for taking SOAP Notes in occupational therapy.

SOAP Progress Notes Template

A SOAP progress note template that helps to improve your clinical notes while saving you time.

SOAP Notes for Psychotherapy Template

Strengthen clinical outcomes, and boost the quality of your care with high-quality SOAP notes for psychotherapy templates.

SOAP Notes for Chiropractic Template

Check out this high-quality SOAP note template for your chiropractic practice. You can support your clients and ensure that you effectively record all relevant health information.

SOAP Notes for ABA Therapy Template

Keep your therapy notes organized with our SOAP Notes for ABA therapy template.

SOAP Notes for Psychology Template

A helpful and intuitive SOAP note template for psychologists looking to improve the accuracy of their documentation while also saving valuable time.

Popular Templates

Panic Disorder Treatment Template

Download Carepatron's free PDF template and example for panic disorder treatment, to guide you in providing effective treatment for individuals experiencing panic disorder.

Rule of Palm

Use our Rule of Palm template for quick and accurate burn size estimation, an essential tool for effective burn management and patient education.

Therapist Rate Increase Letter Template

Notify your clients about changes in therapy practice rates with our comprehensive Therapist Rate Increase Letter Template. Professional and transparent.

Emotional Reasoning Worksheet

Explore identifying and adjusting emotional biases with our Emotional Reasoning Worksheet, designed to enhance decision-making and self-awareness further.

Executive Function Skills by Age Checklist

Develop essential executive function skills with our age-specific checklist and resources. Access Carepatron's free PDF download for tips and guidance.

Choices and Consequences Worksheets

Use our Choices and Consequences Worksheets to teach children and young clients about responsible decision-making.

Posterior Drawer Test (Knee)

Use our Posterior Drawer Test (Knee) template to assess PCL injuries accurately and enhance clinical documentation. Learn more about PCL injuries here.

Ankle Posterior Drawer Test

Assess and diagnose posterior talofibular ligament injuries with Carepatron's Ankle Posterior Drawer Test template, enhancing precision in clinical settings!

Patient Testimonial Template

Gather effective patient testimonials using our Patient Testimonial Template. Share your patient's story to gain prospective patients.

Thought Model Worksheet

Unlock the benefits of cognitive restructuring with our Thought Model Worksheet, designed to enhance therapy sessions and improve mental health outcomes.

Therapy Cancellation Policy Template

Learn the importance of a clear cancellation policy that benefits both therapists and clients! This guide provides a template, explores key elements, and more. 

Interpersonal Effectiveness Skills PDF

Master DBT interpersonal effectiveness skills with our comprehensive guide and worksheet. Help enhance your client's communication skills and relationships.

ADHD Focus Plan

Learn how to create an effective ADHD focus plan with Carepatron's free PDF download. Includes strategies and examples to help individuals with ADHD improve their focus and productivity.

Differentiation of Self Worksheet

Try the Differentiation of Self Worksheet, which enhances emotional and relational health. Gain insights into personal development and improved interactions.

Balance Exercises for Seniors

Improve your balance and stability with these effective balance exercises for seniors. Download Carepatron's free PDF with examples and enhance your overall well-being today.

Cost Benefit Analysis Therapy

Explore the benefits of cost-benefit analysis therapy for decision-making in treatment—ideal for therapists and clients seeking practical problem-solving skills.

Self-Esteem Mirror Worksheet

Download our Self-Esteem Mirror Worksheet to help clients build self-esteem and a positive outlook in life.

Anxiety Thermometer

Download our Anxiety Thermometer template to track anxiety levels. Ideal for young people, parents, and educators. Free PDF example included.

Ruminating Thoughts Worksheet

Discover effective strategies to manage ruminating thoughts with our comprehensive worksheet, designed for mental health improvement and cognitive clarity.

Dyslexia Worksheets

Explore our Dyslexia Worksheets for effective reading, writing, and spelling support. Free examples are included for structured learning.

Should Statements Worksheet

Learn to identify and reframe "should" statements with our Should Statements Worksheet, designed to help you foster more realistic and flexible thinking.

Coping Skills for Paranoia Handout

Carepatron's free PDF download teaches effective coping skills for managing paranoia. It also provides examples and strategies for healthily navigating feelings of paranoia.

Stop Think Act Worksheet

Empower your clients with our Stop-Think-Act Worksheet, designed to enhance emotional regulation and thoughtful decision-making in challenging situations.

Mindfulness Walk Worksheet

Take a break and focus on the present. Download our Mindfulness Walk Worksheet for your mindful walking sessions.

Addiction and the Brain: List of Therapies

Explore the relationship between addiction and the brain, learn about various therapies, and access a free PDF with examples of effective treatment strategies.

Conversation Skills Worksheet

Level up conversational abilities with our engaging Conversation Skills Worksheet. Practical exercises and goal-setting included. Download for free today!

PTSD Dissociation Test

Assess PTSD dissociation symptoms with Carepatron's free PDF download containing a test and examples for evaluation. Get insights and guidance on recognizing symptoms.

Vibrational Emotional Scale

Discover the Vibrational Emotional Scale - explore the spectrum of emotions and their impact on personal growth and well-being.

Articulation Test

Explore our Articulation Test for identifying and treating speech sound disorders, enhancing communication skills, and boosting confidence.

Massage Therapy Invoice Template

Get access to a free Massage Therapy Invoice Template with Carepatron. Streamline your documentation and invoicing process with our PDF.

Health Triangle Worksheets

Explore and improve your well-being across physical, mental, and social health with our comprehensive Health Triangle Worksheets.

Schizophrenia Treatment Guidelines

Discover the latest Schizophrenia Treatment Guidelines, including antipsychotic medication, psychosocial interventions, and cognitive behavioral therapy.

Harm Reduction Worksheets PDF

Make your harm reduction psychotherapy meaningful and effective with the help of the Harm Reduction Worksheets PDF.

Stigma in Addiction Worksheet

Discover how to challenge and overcome the stigma associated with addiction with our free downloadable Stigma in Addiction Worksheet.

Surrender in Recovery Worksheet

Discover a path to recovery with our Surrender in Recovery Worksheet. Embrace change and healing with guided self-reflection. Download the free template.

Medical Fishbone Diagram

Explore the Medical Fishbone Diagram to identify the causes of healthcare issues with our free PDF template. Streamline problem-solving in clinical settings.

Relationship Workbook

Strengthen your relationship with our workbook, offering exercises for better communication, intimacy, and conflict resolution.

Health Anxiety CBT Worksheets

Overcome health anxiety with our CBT worksheets designed to help you understand and manage your fears. Download our free example today.

Physical Therapy Exercise Flow Sheet PDF

Download Carepatron's free PDF of a Physical Therapy Exercise Flow Sheet example to track and document exercises effectively in your therapy practice.

Autism Test for Adults

Make accurate adult autism assessments with our comprehensive testing guide and template. Try them now!

Massage Therapy Business Plan

Creating a massage therapy business plan? Download Carepatron's free PDF to guide you through the process and help you create a successful massage therapy business plan.

Example of Counseling Session Dialogue PDF

Explore a sample counseling session dialogue PDF for insight into effective communication and therapeutic techniques. Download now!

Schizotypal Personality Disorder Test (SPDT)

Explore the use of a self-report tool to screen for symptoms of schizotypal personality disorder among clients. Download a free printable test here!

ACT Bullseye Worksheet

Integrate the ACT Bullseye Worksheet to help clients reflect on and align their goals with their values.

Radical Forgiveness Worksheet

Unlock the power of Radical Forgiveness with our comprehensive worksheet. Guide your patients to healing and transformation with our template and guide.

Family Roles In Addiction Worksheet

Guide families in building a supportive dynamic to aid clients struggling with substance use through their recovery journey.

Teenage Bipolar Test

The teenage bipolar test is a crucial tool for identifying potential mood disorder symptoms in adolescents. Download Carepatron's free PDF example to learn how to administer and interpret the test.

ADHD Planner

Help clients organize effectively with this ADHD Planner. Download Carepatron's free PDF example to better manage tasks and time, specially designed for individuals with ADHD.

OCD Treatment Guidelines

Navigate through the complexities of OCD with our comprehensive treatment guidelines. Discover evidence-based strategies for effective management.

Behavioral Health Treatment Plan

Explore effective mental health treatment plans with our free PDF template, which is ideal for mental health professionals seeking structured recovery paths.

Speech Sound Development Chart

Explore the stages of speech sound development in children, from early vocalizations to complex language use, and how it influences communication and literacy.

Classical Conditioning Worksheet

Explore classical conditioning with our worksheet, perfect for students, therapists, and self-learners to deepen their understanding of behavior theories.

Action Planning Worksheet

Maximize project success with our Action Planning Worksheet. Track and measure progress effectively. Download free templates for complete project management.

Cross Addiction Worksheet

Carepatron offers integrated software for therapy practice management, streamlining scheduling, billing, and clinical documentation for healthcare providers.

Burnout Recovery Plan

Get your free PDF of a burnout recovery plan from Carepatron to help you overcome burnout and regain work-life balance. Explore practical recovery strategies.

Therapy Invoice Template

Our Therapy Invoice Template streamlines billing processes, enhances professionalism, and effortlessly keeps you organized. Download now!

Speech Therapy Invoice Template

Streamline your speech therapy practice with Carepatron's downloadable invoice template and billing software! Save time, ensure accurate billing, and impress clients.

Pisiform Fracture Test

Learn how to conduct the Pisiform Fracture Test. Get a free PDF template to record results and streamline your documentation.

Severity Measure for Social Anxiety Disorder

Explore the Severity Measure for Social Anxiety Disorder to assess the intensity of social anxiety symptoms. Download our template for precise evaluation and treatment planning.

Speech Intelligibility Rating Scale

Download our Speech Intelligibility Rating Scale to assess and improve clarity in speech. Perfect for therapists and educators. Enhance communication now.

Stages of Relapse Worksheet

Download our free Stages of Relapse Worksheet to effectively track and manage signs of emotional, mental, and physical relapse.

Bipolar Treatment Guidelines

Explore expert Bipolar Treatment Guidelines, including diagnosis, symptom management, and personalized care strategies for improved health.

Levels of Hoarding Test

Access a resource that will aid you in evaluating a patient's hoarding disorder. Download our Levels of Hoarding Test today!

Inner Child Worksheets PDF

Try the transformative power of Inner Child Worksheets PDF. Heal past wounds, foster self-discovery, and embrace authenticity with our guide and template.

Mental Health Diagnosis Cheat Sheet

Discover our Mental Health Diagnosis Cheat Sheet for accurate ICD-10 coding, enhancing care and billing in mental health practices.

Antisocial Personality Disorder Treatment Plan

Discover an effective treatment plan for Antisocial Personality Disorder to help individuals manage symptoms and improve quality of life.

Vineland Adaptive Behavior Scale

Learn more about the comprehensive Vineland Adaptive Behavior Scale, which assesses adaptive behaviors in individuals and provides targeted support.

Adjustment Disorder PDF

Navigate the complexities of adjustment disorder with our comprehensive PDF guide. Explore symptoms, diagnosis criteria, and treatment options here.

Authenticity Test

Discover how authentic you are with our Authenticity Test. Uncover your true self, live more authentically, and improve your life satisfaction. Try it now!

IFS Treatment Plan

Download Carepatron's free PDF example of an Internal Family Systems (IFS) treatment plan. Learn how to create a comprehensive treatment plan using IFS therapy techniques.

Premenstrual Dysphoric Disorder DSM-5

Explore the criteria of Premenstrual Dysphoric Disorder (PMDD) as outlined in DSM-5, shedding light on panic disorder and its impact on mental health.

Immature Personality Disorder Test

Assess and understand immature personality disorder with Carepatron's free PDF test and examples. Get insights into this personality disorder and learn more about it.

Stinking Thinking Worksheet

Download our Stinking Thinking Worksheet to help clients challenge negative thoughts and cognitive distortions.

R Worksheets for Speech Therapy

Enhance your speech therapy sessions with R Worksheets, designed to improve articulation skills. Download the free PDF sample today!

Shame Resilience Theory Template

Download a free resource that clients can use for a more goal-directed approach to building shame resilience.

Disruptive Mood Dysregulation Disorder Treatment Plan

Unlock efficient anxiety care with Carepatron's software, featuring patient management tools, secure communication, and streamlined billing.

SCID Assessment

Explore SCID-5-CV, the gold standard for diagnosing mental disorders. Learn how it works and its benefits, and download a free template. Ideal for professionals.

Pediatric Depression Screening Tool

Explore the benefits of Pediatric Depression Screening Tools for early detection and effective treatment in children and adolescents.

Occupational Therapy Acute Care Cheat Sheet

Streamline patient recovery with key strategies for enhancing independence in acute settings. Download our free Occupational Therapy Acute Care Cheat Sheet.

School Readiness Assessment

Discover the benefits of our School Readiness Assessment template with a free PDF download to ensure children are prepared for kindergarten through grade three.

8-Week Group Counseling Plan

Discover a flexible template for creating effective 8-Week Group Counseling Plans, tailored to meet diverse needs and foster growth.

PTSD Treatment Guidelines

Download our PTSD Treatment Guidelines template to access evidence-based treatment plans, diagnostic tools, and personalized care strategies.

DBT House PDF

Learn about DBT House and use it to help patients work through their issues.

Dysarthria Treatment Exercises

Discover effective dysarthria exercises to improve speech clarity. Download our free guide for tailored speech therapy techniques.

Depression Treatment Guidelines

Discover Carepatron - the ultimate mental health software for enhanced care, efficient scheduling, seamless billing, and secure communication.

Antisocial Personality Disorder Test

Use a helpful evidence-based Antisocial Personality Disorder Test to identify ASPD symptoms among clients and improve health outcomes.

Persistent Depressive Disorder Test

Explore an evidence-based screening tool to help diagnose persistent depressive disorder among clients.

Coping Cards

Coping Cards can aid clients in managing distressing emotions. Explore examples, download a free sample, and learn how to integrate them into therapy effectively.

EFT Cycle Worksheet

Download our free EFT Cycle Worksheet example and discover the benefits of integrating it into your practice.

Psychophysiological Assessment

Explore Psychophysiological Assessments with our free template. Understand the link between mental processes and physical responses. Download now.

Occupational Therapy Pediatric Evaluation

Learn about the process of pediatric occupational therapy evaluation. Download Carepatron's free PDF example to assist in understanding and conducting assessments for children.

Coping with Auditory Hallucinations Worksheet

Use our Coping with Auditory Hallucinations Worksheet to help your patients manage and differentiate real sensations from hallucinations effectively.

Gender Dysphoria DSM 5 Criteria

Explore the DSM-5 criteria for Gender Dysphoria with our guide and template, designed to assist with understanding and accurate diagnosis.

Hip Flexor Strain Test

Access our Hip Flexor Strain Test template, designed for healthcare professionals to diagnose and manage hip flexor strains, complete with a detailed guide.

Integrated Treatment Plan

Explore the benefits of Integrated Treatment for dual diagnosis, combining care for mental health and substance abuse for holistic recovery.

Assessing mania symptoms is crucial for mental health awareness. Download Carepatron's free PDF example of a mania test to understand the evaluation process better.

Clinical Evaluation

Explore the process of conducting clinical evaluations and its importance in the therapeutic process. Access a free Clinical Evaluation template to help you get started.

Discover PROMIS 29, a comprehensive tool for measuring patient-reported health outcomes, facilitating better healthcare decision-making.

Back Massage Techniques PDF

Learn various techniques with our Back Massage Techniques PDF. Download our free PDF example to get started today!

Dependent Personality Disorder DSM 5 Criteria

Learn about Dependent Personality Disorder DSM 5 Criteria, understand symptoms and treatment to form healthy relationships. Download the free PDF now.

Apgar Score Chart

Use this Apgar Score Chart template to assess a newborn infant. Click here to download a copy and read a guide on how to score, interpret, and more.

Tinetti Balance Test

Assess your elderly patient’s risk of falling by having them take the Tinetti Balance Test! See how they fare with standing up from an armless chair and measure their gait to get a sense of their risk of falling!

Autism Spectrum Disorder Treatment Plans

Looking for effective and individualized treatment plans for Autism Spectrum Disorder? Our comprehensive templates and progress monitoring can help. Learn more.

Speech Therapy Worksheet

Improve speech and language therapy outcomes with our free worksheets. Distribute to your patients, and collaborate with their speech and communication capabilities to enhance articulation and make significant strides in client progress.

SLP Goal Banks

Enhance your speech-language pathology practice with our SLP Goal Bank. Download the free PDF and achieve better outcomes for your clients to improve their speech patterns and communication functions.

Word Retrieval Worksheet

Enhance adult word retrieval with specialized worksheets: engaging, effective activities tailored for adult language improvement and speech refinement.

Speech Therapy Worksheets for Adults

Speech therapy for adults can be a bit challenging. Improve speech and communication skills effectively with Carepatron's speech therapy for adults PDF.

Explore the comprehensive Dysphagia Test and understand its significance with this free PDF download. Learn about dysphagia assessment today!

Aphasia Worksheets

Discover the Aphasia Worksheets for effective aphasia management. Enhance therapy with Carepatron's software solutions.

VNeST Worksheet PDF

Elevate functional speech with the VNeST Worksheet, guiding clients through engaging activities to practice communication skills and enhance verbal expression.

HIPAA Compliant Software

Discover Carepatron, the ultimate HIPAA-compliant software for healthcare pros. Secure, efficient, & patient-centered—your ideal digital health partner.

Join 10,000+ teams using Carepatron to be more productive

• Skip to primary navigation
• Skip to main content
• Skip to primary sidebar
• Skip to footer

The Orange Effect Foundation

Empowering children and young adults with speech disorders

Writing Excellent SOAP Notes for Speech Therapy: 5 Steps

November 11, 2021 By Orange Effect Administrator

Working with children and adults with a speech impairment is a noble endeavor. You can help hundreds of people overcome their speech disabilities if you dedicate your career to the cause. According to the American Speech-Language-Hearing Association , 5-10% of Americans have some form of communication disorder, with nearly 7% experiencing language impairment, aphasia being most commonplace. 

To make your treatments as effective as possible, you can adopt the SOAP notes writing approach to your medical reports writing. SOAP is an objective, structured way for medical professionals to organize their thoughts and index them for future reference. What is SOAP all about and how can you use it in speech therapy to help your patients overcome their impairments?

SOAP Notes 101 and the Benefits of Utilizing Them

SOAP is a writing system adopted by numerous doctors and medical practitioners around the globe due to its simplicity and flexibility. It is also a built-in feature in many readily available EMR software applications . SOAP is an acronym that consists of four elements:

• Subjective – What does the patient say about their issue?
• Objective – What does the medical exam say about their issue?
• Assessment – What is your professional opinion on the issue?
• Plan – What is your recommended treatment for the issue?

There are numerous reasons to use SOAP to write your notes in speech therapy . Whether you’re working in a hospital or as a private practitioner, SOAP will make your job easier by helping you organize your findings. You will be able to outline exactly what the patient thinks about their ailment and then write your conclusions to the physical exam after. This helps reduce the length of the examination, makes storing patient data more straightforward, and enables you to recommend the right speech therapy for your patients.

Writing Excellent SOAP Notes for Speech Therapy

• Create a Template to Fill in with Patient Information

Creating a template for your SOAP notes before seeing your speech-impaired patients will make your meetings more productive. With a template consisting of four separate subheadings, you can take quick notes while also talking to them actively. This will allow you to pay more attention to what they’re saying and write down notes between checking their current condition. Your template can be created in a traditional text editor, a cloud writing platform, or an EMR app. For private practitioners, renting EMR software may be pricey so alternatives are also welcome.

• Write Down Keywords and Phrases without Complex Sentences

To speed up the process of taking SOAP notes, you should avoid writing complex sentences with paragraphs of text. There is no need for you to thoroughly explain what happened in the meeting in great detail – you were there. The notes you take are there to help you keep track of your speech impaired patients and no one apart from you will see them. This means you can write notes in whichever style you like, be it by writing keywords down or a short sentence for each SOAP element.

• Take New Notes Whenever You See Patients Again

Given that you are likely to see the same patients more than once, you should take new SOAP notes every time. Your patients’ condition may have changed and you might notice improvements or declines in their speech therapy. Comparing new notes to previous sessions will allow you to map out a better treatment program for each patient. Moreover, it will ensure that you don’t overlook even the most minor detail in your SOAP notes.

• Date, Sign, and Double-Check your Notes After Sessions

To keep things as organized as possible, you should date and sign your SOAP notes whenever you’re done with them. Once your session has finished, go over what you wrote to spot any grammar mistakes or formatting issues. Be especially mindful of the treatment and medicine prescription you’ve assigned (if any) since spelling errors can have consequences. When you’re satisfied with the SOAP notes you took for that session, add your physical or digital signature to the document and file it away.

• Write Down Key Takeaways from the Session in Freehand

It’s always a good idea to outline the key points and takeaways you took from the speech therapy session. In your personal opinion, how well is the patient handling their treatment and how can you help them get closer to their goals? Speech treatment is a highly subjective field where no two patients have the same diagnosis or the extent of it. Think about the SOAP notes you wrote down and write a takeaway for the session before closing the file for now.

SOAP Notes for Speech Therapy Writing Mistakes to Avoid

Now that we’ve seen how SOAP notes can help you in treating speech impairment, it’s important to note several potential mistakes to avoid. While SOAP is extremely effective at helping you organize, you can also find yourself in a position where you automatically, mandatorily fill in blanks. 

According to a published medical study , SOAP can often narrow your field of view by requiring you to follow a set path toward treatment. In it, the writers postulated that APSO (Assessment, Plan, Subjective, Objective) may be more practical and that SOAP should be retrofitted on a case-by-case basis. Each entry in your medical reports has to be written meaningfully and with good reasons – which is why you should avoid the following:

• Writing unsourced, anonymous entries into your SOAP notes
• Avoid unclear sentences without conclusions or tangible data
• Don’t repeat yourself in your SOAP notes – only state certain things once
• Write original treatments and recommendations for each patient – don’t copy/paste
• Always proofread, format, and sign your SOAP notes

The purpose of using SOAP for your notes for speech therapy is to ultimately make treating your patients easier. It is a convenient, tried, and tested system for organizing patient findings and writing medical reports. 

Today, SOAP is best used via a dedicated EMR app which would make indexing and storing patient data easier than through manual writing. Consider the steps outlined in the previous paragraphs in your practice and see if you can use them to improve your patients’ wellbeing. Even if all it does is help organize your writing, SOAP is still a worthwhile addition to any medical practitioner’s toolset.

Jessica Fender is a researcher and academic content creator. Her job is to facilitate student learning – she creates educational content that aligns with search queries “ write my thesis for me ” and “hire writer.” When Jessica has free time, she enjoys reading, blogging, and hiking.

About Orange Effect Administrator

Meet the Voice Behind the Orange Effect Foundation - your go-to source for valuable insights and resources! The Orange Effect Administrator curates and shares posts tailored for speech therapists, passionate OEF supporters, grant recipients, and parents of children facing speech disorders. Explore our blog to stay informed, inspired, and connected with our vibrant community.

17040 Amber Drive Cleveland, OH 44111 [email protected]

Copyright 2024 orange effect foundation. all rights reserved..

Therapy Brands Celebrates Mental Health Providers!

Mental Health Awareness Month

How to write a soap note for speech therapy.

As a pediatric speech therapist, you know that defensible documentation (i.e., clear and detailed notes) is an essential part of demonstrating your skilled service and getting paid.

Whether you use  clinic software  or the old pen and paper method, managing your SOAP notes and evaluations can easily become overwhelming when working with multiple patients. But you don’t have to let that affect the quality of your notes.

In this article, I’ll cover some guidelines you can follow to improve your SLP documentation with or without  speech therapy documentation software . And remember: better notes mean better therapy and less claim denials.

While every SLP has their own way to document their sessions, these guidelines can help you write notes that include the critical information and present those details in a way that’s easy to digest for caregivers and other therapists. I’ve also included a SOAP note template and some other helpful resources at the bottom of the post.

Feel free to take this information and tailor it to your own note-taking style!

What is the SOAP method?

If you need a refresher on the SOAP method of note taking here’s a reminder:

• S: Subjective.  This is a statement about the relevant status or behavior that has been observed in your patient. Example: “Patient’s father said, ‘Her teacher said she can understand her better now.’”
• O: Objective.  This section includes quantifiable, measurable, and observable data. “The patient produced /l/ in the final position of words with 70% accuracy.”
• A: Assessment.  This is where you interpret what “S” and “O” mean in your report. Example: “The patient’s pronunciation has improved 10% since the last session with visual cues of tongue placement.”
• P: Plan.  This is where you look ahead to anticipate the number of sessions needed and what the next session will involve. Example: The patient continues to improve with /I/ in the final position and is reaching goal status of /I/ in the initial position. The next session will focus on /I/ in the medial position.

Whether you’re using our SOAP note template, or you’re creating a template of your own, it will help to keep those details in mind.

How to Write a SOAP Note

The  elements of a good SOAP note  are largely the same regardless of your discipline.

Your SOAP notes should be no more than 1-2 pages long for each session. A given section will probably have 1-2 paragraphs in all (up to 3 when absolutely necessary).

That’s enough to give a solid overview of what each session involved, how the patient is progressing, and what you anticipate working on in the near future.

Consistency

Keep in mind that length requirements, exact formats, and abbreviations vary from one employer to the next. This is where a template can come in handy.

You should never hesitate to check your employee handbook or ask about the best way for you to handle your SOAP notes so that they are consistent with what your supervisors want to see.

Whenever you’re writing a SOAP note, be sure to keep its purpose in mind. Oftentimes, speech therapists write so many notes that they occasionally lose sight of the real purpose of these notes.

The purpose is to clearly inform caregivers and other therapists about the patient’s current status and progress. They’re also used to document the need for these sessions to an insurance company so that you can be reimbursed.

7 Documentation Guidelines for Better SLP SOAP Notes

Here are seven documentation guidelines that will help improve the quality of your SOAP Notes as a Speech-Language Pathologist.

#1 Use a template

Following a template will be beneficial to your management and organization techniques. You can find plenty of templates online and then adapt them to fit your own unique approach. (In fact, here’s a  free SLP SOAP note template !)

You may not always fill out every section of the template for every patient report. If that’s the case, simply leave those sections blank and write in the information that’s important where it belongs.

Following a consistent structure will help you with reference, organization, and comparisons later on. It will improve your level of detailed documentation while also making it easier for you to “fill in the blanks” and finish your notes accurately.

A SOAP note template will also make sure that you are consistently tracking the most important information for each patient.

#2 Write a note for each session

In order to write defensible documentation, you should be creating a unique note for each and every appointment.

The note that you create for each child following every session should describe the patient’s goals and treatment in a way that’s relevant to each individual patient. Different activities and interventions should be clearly justified.

Avoid “cookie cutter” notes that are generic, vague, and/or look the same for all the children you work with. These are a red flag for insurance claims reviewers.

If you’re using EMR software, you should find an option with a wide selection of content that’s able to be customized with unique responses, outcomes, and goals tailored to each child.

#3 Figure out the patient’s goals

When it comes to your SOAP notes, writing goals is crucial. However, setting too many goals can hinder your treatment plan. So be specific to each patient when prioritizing the goals and think about what limitations are the most challenging for them in day-to-day life.

When you create goals, be sure that they are  SMART goals . SMART goals are easier for caregivers and other involved parties to digest and support.

A SMART goal is:

• Relevant, and
• Time-Based.

SMART goals break down a goal so that you can look at each aspect and set a date for the goal to be reached.

They also allow you to plan what needs to happen along the way for you to get there.

Make sure each patient’s long-term goals are as functional as possible. You should set short-term goals that help them reach their long-term goals incrementally, keeping them motivated and on the right path.

#4 Don’t put your notes off

The best time to complete your notes is immediately after a session when everything is fresh in your mind. Putting off your notes will increase how long it will take you to be reimbursed for the treatment.

Additionally, the further removed you are from a session, the less you will be able to remember when it comes time to write your notes. This can hinder the treatment plan and lead to you forgetting important details.

#5 Ensure your notes are neat

If you are not using an electronic system and you have opted for pen and paper, be sure that your notes are neat and legible, not only for yourself but for your patients and their caregivers as well. Your notes should be easy to read and structured in a very clear, streamlined way.

One way to keep your notes easy to read is to print out your template and writing directly into the note when it makes sense (even if you don’t use that as your final note).

#6 Include the session’s important points

Documenting each individual session is how you provide evidence about the quality and efficacy of your treatment plan. When you forget or exclude details, caregivers can begin to question the quality of the care you’re providing.

The more details you’re able to write about a given session, the better. These details will help you stay consistent with your treatment methods and replicate your approach where needed.

They can also help you better communicate with other therapists who may be working with your patients to ensure they can pick up where you left off.

#7 Exclude unnecessary information

While you should be detailed with your reports and include all the important and pertinent information, don’t fill your reports with unnecessary information. This makes it harder to read, longer to write, and more difficult for others to process. It will also clutter your note review process.

Focus on writing better, not necessarily more. Know what information is needed in order to tell the story of functional outcomes and medical necessity for your treatment plan.

That’s how you write good notes that will ultimately be reimbursed.

Other Documentation Tips

Here are a few extra tips to help you with your documentation. Like the guidelines above, these tips will help reduce claim denials and improve the effectiveness of your therapy.

Use Speech Therapy Documentation Software

If you have not already begun to use  therapy documentation software  to keep track of your SOAP notes, there is no better time to start. Nothing beats the versatility, ease of sharing, and security of good  speech therapy practice management software .

There are multiple systems out there that you may use to handle your SOAP notes. Your clinic may even already have one in place. If that’s the case, your priority should be learning how to use the system to the fullest.

Oftentimes, even if you know how the basics (like how to create and submit a new note), you may be missing out on some valuable tools that you haven’t yet learned how to access.

On the other hand, if you are still using pen and paper or just a basic Word template for your notes, it’s worth looking into an electronic system that can help you submit your notes more efficiently and be more accurate with your note-taking.

You can find both locally installed software for your work computer and even some  cloud-based platforms  that can be accessed online whenever you need them.

As times goes by and these systems become more advanced and convenient, it’s likely your clinic will be switching to one in the future anyway. Getting ahead of the curve and learning how to use one of the more popular systems can help you stay relevant in the workforce and may even open up new doors for you at another clinic where such systems are already in place.

Foster Positive Development

Perhaps the absolute best advice you can take as a SLP is getting caregivers actively involved in the speech development of their child. In your SOAP notes, you should be sure to document all home education programs and other activities the child is participating in to help develop their skills.

This is also required by many insurance companies who have requirements for caregiver education and home programs. You should document all education that you are providing to the caregiver including any training you provided about interventions and strategies they can implement at home.

Double-Check Your Notes

In addition to including pertinent information that will help your patient with their development, you also need to double-check all your notes against a template and your clinical guidelines to ensure that you will be reimbursed by the insurance company for your work.

You should also know what services you should be billing for and make sure you are documenting them accurately. Additionally, know when you should bill for the time spent completing your notes as that can be a time-consuming process as well.

Use Action Words

Using action words helps to demonstrate the skilled services that you are providing, which is something insurance companies look for when reviewing claims.

You can find multiple “cheat sheets” online filled with action words tailored for your SLP SOAP notes. These action words can help speed up the note-taking process while also assisting you with documenting the skilled speech therapy services you are providing. accurate, detailed documentation for each session you complete with a patient.

Some key action words include: adapted, addressed, adjusted, clarified, coached, collected, delivered, demonstrated, drilled, established, evaluated, expanded, familiarized, formulated, guided, habituated, identified, initiated, monitored, observed, prompted, reinforced, and so on.

The use of action words can help better illustrate a challenge, progress, or goal that you are attempting to document. Using the right action words can help make your notes clearer and more concise while adding significant value to everything you detail about a given session.

Study Good Examples

The last tip for perfecting your SOAP note-taking method, is to find some great examples to learn from.

Search the web for sample SOAP notes for speech language therapy or ask your colleagues for examples of well done SOAP notes. Then you can model the structure and flow of your notes on them.

• Therapy Brands
• July 18, 2018

Related Posts

6 Tips for Managing Your ABA Practice Remotely

How to Find the Right Billing Solution for your Healthcare Practice

The Benefits of Incorporating Lab Results in Your EHR

5 Things to Consider When Choosing a New EHR for Your Mental and Behavioral Health Practice

How Electronic Prescriptions Prevent Doctor Shopping

Mental Health Claims Processing Overview

How EHRs Can Enhance Their Offerings with a Clearinghouse Partnership

Understanding Value-Based Care and Its Impact on the Billing Cycle for Clinicians

How to Grow Your Medical Practice with Electronic Prescription

How to Maintain Healthy Habits During Times of High Stress

• Documentation
• Interoperability
• Billing Software
• Online Scheduling
• Digital Intake
• Patient Payments
• Deals for PT
• Clinicient.com
• Keethealth.com

Better SOAP note documentation for PTs, OTs, and SLPs.

Our tips on this tried-and-true formula for reducing the rate of billing errors at your practice.

Proper medical documentation requires dedicated time and knowledge, creating a serious pain point for busy physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs). It takes practice to correctly document each patient appointment quickly while remaining compliant with payer requirements.

But without detailed notes, providers risk billing errors, delays, and denied reimbursements. In turn, profit margins are impacted, and the high demand and lack of time have the potential to lead to provider burnout as they struggle to meet documentation requirements of Medicare and private insurance companies.

You probably already know that relying on the SOAP format can help alleviate the stress of proper billing and coding. After all, it’s been the standard for compliant patient documentation for more than 70 years.

Even though you know how to use SOAP, brushing up on your technique can help you save time on documentation without compromising defensible claims for outpatient rehabilitation services. With this guide, learn how to use SOAP to your advantage for SLP, OT, or PT practice billing with tips, tricks, and smart strategies for success.

The top priority: Defensible Documentation

SOAP is the primary documentation method of health care providers, including physicians, nurses, and rehabilitation therapists.

While most payers accept SOAP as an appropriate documentation format for insurance claims, defensible documentation must go beyond the basics of subjective, objective, assessment, and plan. SOAP notes are designed to be short and factual, so they are easy for other providers to read and interpret, which also improves the continuity of care for patients.

However, many providers struggle to balance concise simplicity with the detail required for defensible claims. Reviewing SOAP note examples can help you become more familiar with this widespread format and how to perfect it for yourself.

But what SOAP really relies on in an outpatient rehab therapy setting is documenting defensibly. Defensible documentation provides proof of medical necessity if an insurance audit arises. Most payers also require this proof for SLP, OT, and PT services before reimbursing claims.

To meet the expected standards of proof, make sure all SOAP notes are standardized for your practice and match others in your specialty.  Notes should be clear, concise, non-judgmental, and focused entirely on the patient and their care plan.

The fundamentals of medical documentation

When done correctly, solid medical documentation can help providers receive reimbursement more quickly, provide protection from legal liability, and create an understandable reference for physicians and other care providers who may also treat your patients. As SOAP has been in use for over 70 years, providers have found sound documentation often meets four principles :

• It illustrates a clear, thoughtful process for patient assessment and care.
• It demonstrates use of sound clinical judgment.
• It shows the patient’s capacity to participate in care planning and decision-making.
• It adheres to payer guidelines with inclusion of treatment goals, diagnosis, types of services, and frequency and duration of treatment sessions.

Remember that taking good notes does not necessarily mean writing longer notes. Instead, focus on communicating the necessary information as concisely as possible.

Our six tricks to improve your SOAP notes

If you’re new to the SOAP format, strategic notetaking can feel unnatural at first. Enhance defensibility and clarity of patient documentation with these valuable SOAP note tips:

• Use Templates: Use EMR-based templates rather than writing brand-new notes for each new patient. For example, Clinicient’s EMR, the Insight Platform , allows providers to choose between narrative note templates and those that require them to complete a fill-in-the-blank form. The use of templates creates a consistency that improves organization and readability, reduces costly errors, and saves valuable provider time.
• Be Mobile: Document at the point of care with your tablet or smartphone to avoid missing important details. That way if you’re performing exercises with your patient, you can still notate your observations, assessments, and treatment goals quickly. Mobile tools like voice-to-text can make your documentation even faster.
• Write Reminders: If you can’t complete the patient’s documentation during their visit, keep short reminder notes to help you recall details for later. Write down numbers, facts, and other items you might not recall precisely after the session.
• Create SMART Goals: Use the SMART method to set goals (specific, measurable, achievable, relevant, and time-bound). This framework provides a way for the patient and therapy team to track progress objectively and collaboratively.
• Use Active Voice: Use action words like observed, established, coached, adapted, assessed, or evaluated. This helps you keep notes in active voice rather than passive voice for better clarity and readability.
• Write For Relevance: Leave out details that do not support the medical necessity of the patient’s treatment plan. If you aren’t sure, ask yourself whether the payer will find the information you shared is relevant to approving the claim. Will it impact the defensibility of your notes? Can payers get a full scope of the processes performed during the patient visit? Be critical, and don’t be afraid to trim unnecessary information.

SOAP note example for occupational therapy

For our occupational therapy example, we’ll be documenting a patient visit whose goals include developing and using a functional grip with writing tools, as well as crossing the midline when engaging in these activities.

Subjective: Document the patient’s report of their injury or condition, as well as their caregiver’s report, if applicable.

The patient entered the appointment room and said he is very tired today. His parent said he uses his right hand about two-thirds of the time and switches to the left hand the other third.

Objective: In this section, write what you observe during the session with the patient.

The patient used a violin grasp in about 20 percent of writing opportunities during the session and a digital pronate grip during the other 80 percent of opportunities. He tends to switch to the left hand when the utensil has been placed on the left. Patient uses the elbow and shoulder to generate coloring movement. He used his hands for neck support with elbows propped on the table and fell out of his chair twice. He required verbal prompts to cross the midline in 50 percent of exercises.

Assessment: In this section, you note your evaluation of the patient’s progress.

The patient still displays emerging hand dominance. He lacks postural control and proximal stability because of challenges with the small hand muscle isolation necessary for functional grasp.

Plan: In this section, document the next steps for your patient based on the assessment.

Support teachers and caregivers with midline crossing resources and activities. Continue 60 mins OT 1x/week to work on grasp and midline crossing. Possible referral to PT for postural control issues, continue to monitor. Offer short writing utensils to help support development of grasp.

SOAP note example for physical therapy

In this SOAP note example for physical therapy, we look at documentation for a male patient in his 60s referred with knee pain.

The patient said he has had left knee pain for about five years before first seeking treatment in late 2020. He was diagnosed with arthritis and had total knee replacement in May 2021. His recovery went smoothly, and he wants to regain mobility and function.

Patient uses a walker and favors his left knee. He describes increased pain when flexing the knee as well as along the incision, which is healing well and has no open areas. Lower extremity functional outcome score revealed disability of 55 percent.

Patient problems include impaired gait, limited home exercise, impacted posture, inability to bear weight on the knee, diminished balance, strength, and range of motion in the knee, and increased pain in the knee.

Patient should continue 2x weekly PT appointments for six weeks and receive reassessment for progress after six to eight visits. Treatments will include strengthening exercises, balance training, posture and body mechanics training, ice application, and neuromuscular exercises.

SOAP note example for speech therapy

If you’re wondering how to write better SOAP notes for speech therapy, study this example of a woman in her 80s struggling with language issues after having a stroke.

Although the patient was tired after being awakened from her nap, she quickly became alert and participated throughout the session. She expressed a positive attitude about therapy and feels pleased with the progress she has made in language.

The patient displayed eight instances of paraphasia during the session and acknowledged the errors about 75 percent of the time. She also had six instances of anomia and was able to find the misplaced word about 50 percent of the time.

The patient is making progress with her language goals, as evidenced by the ability to recognize anomia and paraphasia. Over time, she will be able to adjust to these challenges and recall more words. She also benefits from significant family support.

The next session will involve the patient’s family as we work to transition her out of speech-language therapy. The team will continue to provide encouragement and cues as needed, in addition to assisting the family and patient with strategies and resources.

Improve documentation compliance and speed with the right EMR for your clinic

While clinical documentation challenges providers across the medical spectrum, practice makes perfect when it comes to taking defensible notes and reducing the rate of rejected claims.

If your clinic is looking for a simple EMR with customizable documentation templates, a mobile-friendly interface, and built-in billing automation, connect with our team to hear more about our Insight Platform. Schedule a free, no-obligation demo today.

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

Save my name, email, and website in this browser for the next time I comment.

Related Content

5 things all practice owners must do for better documentation

The complete Medicare guide for physical, occupational, and speech therapy.

Which Type of Documenter Are You? The 7 Styles of Therapist Documentation

• Therapy Tools

Writing SOAP Notes, Step-by-Step: Examples + Templates

Documentation is never the main draw of a helping profession, but progress notes are essential to great patient care. By providing a helpful template for therapists and healthcare providers, SOAP notes can reduce admin time while improving communication between all parties involved in a patient’s care.

In a few sections, we’ll give a clear overview of how therapy SOAP notes are written, along with helpful templates and software you can use to streamline the process even further. If you’re looking for a more efficient, concise way to document your telehealth sessions, this helpful guide will be of value.

How To Write Therapy SOAP Notes

Therapy SOAP notes follow a distinct structure that allows medical and mental health professionals to organize their progress notes precisely. [1]

As standardized documentation guidelines, they help practitioners assess, diagnose, and treat clients using information from their observations and interactions.

Importantly, therapy SOAP notes include vital information on a patient’s health status. This information can be shared with other stakeholders involved in their wellbeing for a more informed, collaborative approach to their care, as shown:

It’s critical to remember that digital SOAP notes must be shared securely and privately, using a HIPAA-compliant teletherapy platform . Here, we used Quenza.

The S.O.A.P Acronym

SOAP is an acronym for the 4 sections, or headings, that each progress note contains:

• Subjective: Where a client’s subjective experiences, feelings, or perspectives are recorded. This might include subjective information from a patient’s guardian or someone else involved in their care.
• Objective: For a more complete overview of a client’s health or mental status, Objective information must also be recorded. This section records substantive data, such as facts and details from the therapy session.
• Assessment: Practitioners use their clinical reasoning to record information here about a patient’s diagnosis or health status. A detailed Assessment section should integrate “subjective” and “objective” data in a professional interpretation of all the evidence thus far, and
• Plan: Where future actions are outlined. This section relates to a patient’s treatment plan and any amendments that might be made to it.

A well-completed SOAP note is a useful reference point within a patient’s health record. Like BIRP notes , the SOAP format itself is a useful checklist for clinicians while documenting a patient’s therapeutic progress.[REFERENCE ITEM=”Sando, K. R., Skoy, E., Bradley, C., Frenzel, J., Kirwin, J., & Urteaga, E. (2017). Assessment of SOAP note evaluation tools in colleges and schools of pharmacy. Currents in Pharmacy Teaching and Learning, 9 (4), 576.”]

In the next section, you’ll find an even more in-depth template for SOAP notes that can be used in a wide range of therapeutic sectors.

Therapy SOAP notes include vital information on a client’s health status; this can be shared with other stakeholders for more informed, collaborative patient care.

3 Helpful Templates and Formats

With a solid grasp of the SOAP acronym, you as a practitioner can improve the informative power of your P rogress Notes, as well as the speed with which you write them. 

This generally translates into more one-on-one patient time, reduced misunderstandings, and improved health outcomes overall – so the table below should be useful.

SOAP Notes: A Step-By-Step Guide

Podder and colleagues give a great overview of the different subsections that a SOAP progress note can include. Based on their extensive article, we’ve created the following example that you can use as guidance in your work. [1]

Occupational Therapy SOAP Notes

In Occupational Therapy , a SOAP Progress Note might include the patient’s injuries and their severity, home exercises, and their effectiveness.

Based on observations and interaction with their client, an OT professional might adjust their treatment program accordingly. [2]

Laid out in the S, O, A, P format on therapy notes software , they might look like this:

Digital SOAP note tools like Quenza, which we’ve used here, will automatically create PDF copies for download, sharing, or HIPAA-compliant storage in a centralized place.

Because SOAP notes are best created while a session is still fresh in their minds, therapists might look for mobile-compatible software. This way, notes can be made on the spot from a tablet or smartphone.

Recommended: How to write Occupational Therapy SOAP Notes (+3 Examples)

Applied Behavior Analysis SOAP Notes

SOAP notes also play a valuable role in Applied Behavior Analysis , by allowing professionals to organize sessions better and communicate with a client’s other medical professionals. Legally, they may also accompany insurance claims to evidence the service being provided. [3]

It is important to remember that ABA SOAP notes , as psychotherapeutic documents, must be stored privately. They may form part of a client’s overall medical file other therapy notes.

These illustrative Occupational Therapy SOAP Notes and ABA SOAP Notes also exemplify how versatile SOAP notes can be. [4]

It’s why the framework is a commonly used standard in sectors such as Physical Therapy , Nursing, Rehabilitation, Speech Therapy , and more.

5 Examples of Effective Note-Taking

Many therapy software systems help to speed up the documentation of progress notes through in-built templates and diagnostic codes. At the end of the day, however, clinically valuable notes require careful thought and judgment when it comes to their content.

Effective notes are generally: [5]

• Written immediately following a therapy session. This way, a practitioner’s in-session time is spent focused on patient engagement and care ; writing notes immediately after helps minimize common mistakes such as forgetting details or recall bias.
• Professional. An important part of patient Electronic Health Records , SOAP notes should be legible and make use of professional jargon to serve as a common frame of reference. They should be written in the present tense.
• Concise and specific. Overly wordy progress notes unnecessarily complicate the decision-making process for other practitioners involved in a patient’s care. Brief, but pertinent information helps other providers reach conclusions more efficiently.
• Unbiased: In the Subjective section, particularly, there is little need for practitioners to use weighty statements, overly positive, negative, or otherwise judgmental language. SOAP notes are frequently used both as legal documents and in insurance claims.
• Utilize appropriate details, such as direct quotes: For a more comprehensive document that includes all the salient facts of an encounter.

An effective SOAP note is a useful reference point in a patient’s health record, helping improve patient satisfaction and quality of care.

3 Smart Software Solutions

In this section, we’ve reviewed three of the top  practice management software systems offering helpful SOAP note functions.

These include SOAP note templates, discipline-specific codes, and treatment planning features that integrate with therapy progress notes.

Final Thoughts

With clear, consistent information on a patient’s health status and progress, therapists, psychiatrists, and counselors are much better equipped to manage their well-being. And while note-taking may not be glamorous, harnessing the right software can significantly reduce the time you spend on this vital part of healthcare .

SOAP notes play a pivotal role in streamlined, effective healthcare, and are a daily part of life for many practitioners. If you’ve tried and enjoyed using any particular templates, forms, or therapy notes solutions, let us know in a comment.

We hope this article has helped you streamline your note-taking. To put these tips into practice, don’t forget to try Quenza’s SOAP Notes tools for just $1 a month .

If you want to enhance the wellbeing of your clients more effectively, Quenza will give you everything you need to streamline your therapy notes, so you can focus on delivering the wellness results that matter.

• ^ Podder, V., Lew, V., & Ghassemzadeh, S. (2020). SOAP Notes. StatPearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482263/
• ^ Fusion Therapy. (2020). How To Write Therapy SOAP Notes.. Retrieved from: https://blog.fusionwebclinic.com/soap-notes-for-occupational-therapy
• ^ WebABA. (2020). Simple Guidelines for Writing SOAP Notes. Retrieved from https://webaba.com/2020/07/01/aba-practice-daily-simple-guidelines-for-writing-soap-notes/
• ^ Belden, J. L., Koopman, R. J., Patil, S. J., Lowrance, N. J., Petroski, G. F., & Smith, J. B. (2017). Dynamic electronic health record note prototype: seeing more by showing less. The Journal of the American Board of Family Medicine, 30 (6), 691.
• ^ Fusion Therapy. (2020). How To Write Therapy SOAP Notes. Retrieved from: https://blog.fusionwebclinic.com/soap-notes-for-occupational-therapy

thanks for info

Leave a reply Cancel

Your email address will not be published.

Download free guide (PDF)

Discover how to engage your clients on autopilot while radically scaling your coaching practice.

Coach, This Changes Everything (Free PDF)

Update on the Current Change Healthcare Outage

Click here for Therapy Brands FAQs

A Pediatric SOAP Note Example and Helpful Tips for SLPs

We write them every day, but many of us still have questions about how to correctly write a SOAP note. How do you write notes that are simple and also cover all documentation requirements without spending hours for each patient? Here’s your guide to writing SOAP notes quickly and correctly, with examples.

SOAP Note Basics

First, ask yourself why you’re writing this SOAP note-  who will see it and what information should it convey? ASHA recommends that clinical notes be comprehensive enough that another SLP could read it and understand your therapy process enough that they could pick up where you left off to continue therapy. Here are examples of each section of a good SOAP note:

S: Subjective

Your impressions of the patient’s level of awareness, mood, and behavior. You can also include direct quotes from the patient. This is a good place to include how a patient feels about their speech improvement or therapy in general.

EXAMPLE: Suzy appeared alert and attentive during the entirety of the session. Her mother reported that Suzy said “I was looking forward to speech all week!”, and that Suzy’s teacher remarked that she has been able to understand Suzy better in the past week.

O: Objective

Measurable information (e.g. data) , including percentages and which goals and objectives were addressed. You can also include the activity that was used to elicit this data.

EXAMPLE: Suzy produced /k/ at the beginning of words with 70% accuracy using a worksheet with 10 /k/ vs /t/ minimal pairs, given 2 verbal reminders (e.g.“Is it Tar or Kar?”) and a mirror for self-correction.

A: Assessment

Your analysis of the session. If possible, compare the patient’s performance across sessions.

EXAMPLE: Suzy’s correct production of /k/ in initial position increased from 60% in imitation and with a visual aid during the last session to 70% during today’s session. Omission of visual aid (picture of mouth producing /l/ sound) did not decrease performance.

Outline the course of treatment and therapy targets for the next session. Include possible activities, plan for reinforcement/cuing, and any changes to objectives, as well as any homework you send home.

EXAMPLE: Suzy continues to improve her production of initial /k/. Continue to fade cues and initial model of the sound for initial /k/ at next session. Sent home 3 minimal pair worksheets from XYZ book and directed Suzy’s mom how to complete them.

Check out this free SOAP note kit that includes a template, checklist, even more SOAP note examples, and 7 Tips to Improve Your Documentation.

Finally, a few more tips for writing better SOAP notes:

Write the notes as soon as you can after the session, or during the last few minutes if allowed. This keeps the information fresh in your mind.

Don’t forget to document any homework you sent home in the Plan section. This will help you know where to start for the next session.

Take advantage of copy-and-paste features if you use an EMR. This allows you to copy the past note and make relevant changes, which is great for therapy that uses similar activities and goals each time.

Fusion Web Clinic makes writing SOAP notes easy with templates, quick phrases, and goal tracking, on the web or on mobile! Check out our documentation page for more information!

About the Author:

Jill Shook, MS, CCC-SLP owns a private practice in Pittsburgh, PA. She created a course for SLPs starting out in private practice, which is available through Northern Speech Services, and blogs about resources for SLPs in private practice at Private Practice SLP .  Email her at [email protected]

Free SOAP Note Kit

This kit includes:

• SOAP Note Template
• 7 Tips to Improve Your Pediatric Documentation Handout
• SOAP Note Checklist Handout
• SOAP Note Examples

3 SOAP Note Examples to Help You Write Progress Notes

As a health professional, writing progress notes is a time-consuming part of the job. Using tailored models is key to an efficient writing process and standardized notes.

In this article, we'll delve deeper into an effective way for consistently documenting your client's information: SOAP notes.

We’ll explore each component, provide tips and SOAP note examples for effective documentation.

Whether you're new to using SOAP notes or looking to refresh your knowledge, this guide will help you write clear, concise, and comprehensive SOAP notes.

What is a SOAP note?

SOAP notes are a widely used method of documentation in the healthcare field, particularly in settings where a client's progress needs to be tracked over time.

The SOAP note format was developed by Dr. Lawrence Weed in the 1960's as a way to organize client information in a structured and concise manner. It was initially used in medical records but has since been adopted across various healthcare disciplines, including mental health, occupational therapy, social work, speech therapy, and more.

One of the key strengths of SOAP notes is their effectiveness in documenting progress and conveying relevant information about the client. Whether you're a mental health counsellor documenting a therapy session, an occupational therapist assessing a client's progress, or a speech therapist tracking a client's language development, the SOAP format provides a systematic approach to documentation.

SOAP stands for:

• S Subjective
• O Objective
• A Assessment

SOAP Note Variations

In addition to the traditional SOAP format, there are variations that offer slightly different structures and focuses that may be taken into consideration when choosing a template.

APSO Notes : The APSO format places the Assessment and Plan first, followed by the Subjective and Objective information. APSO notes are often used in settings where the assessment and plan are the primary focus, and require even easier access.

SOAPE Notes : The SOAPE format adds an Education or Evaluation section after the Assessment. This format is particularly useful when documenting an evaluation of the plan or advice transmitted to the client about various aspects of the treatment process is important.

Ultimately, the choice of format should align with the goals of the documentation and the specific needs of the setting. Whether using the traditional SOAP format or one of its variations, the key is to ensure that the note is organized, concise, and effectively communicates the necessary information for continuity of care or evaluation.

Best practices for writing effective SOAP notes

Progress notes are not only a legal requirement for certified mental health professionals, but must also comply with specific standards for both public and private contexts. When writing a progress note, it's essential to consider the following criteria to determine which information to include:

• Relevance: Ensure that the information is pertinent to the client's treatment and progress.
• Organization: Arrange the information in a clear and logical manner.
• Conciseness: Be brief and to the point, avoid unnecessary details.
• Objectivity: Present factual information without personal bias or interpretation.
• Accuracy: Ensure that the information is correct and reflects the client's actual progress.
• Clarity: Use straightforward and easy-to-understand language.
• Legibility: Write in a neat and readable manner.
• Spelling: Check for and correct any spelling errors.

When writing a SOAP note, it’s important to follow the general guidelines for progress notes. The information under each heading should be relevant to the client in question and to the specific consultation context.

Here are some tips for each section:

This section focuses on subjective information that is gathered directly from the client. It should be relevant to the service request and intervention plan. It should not include interpretations and must be verified, with the source clearly identified.

• Client perceptions
• Problem description and its manifestation from the client's perspective
• Social and family context
• Expressed goals, frustrations, complaints, and expectations
• Client’s suggestions for improving their situation
• Assessment of the person’s health (mental, physical) and the intervention plan
• Reported medical and social history, including response to previous treatments and medications
• Information provided by third parties
• Relevant citations

Here, focus on objective observations that can be described clearly as facts. This includes descriptions of behaviours or activities.

• The client's appearance, behaviour or mood
• Manifestations of the client's problem (symptoms)
• Relevant information provided by other professionals
• Results and changes related to the intervention plan

In this section, integrate the subjective and objective information gathered in the previous sections to form your professional opinion.

• Professional understanding guiding the intervention plan or specific actions.
• Clinical understanding of the client’s assessment over time.
• Psychosocial assessment or reassessment.
• Predictions, conclusions, or risk factors.

This section allows you to:

• Identify the problem(s) (diagnosis).
• Justify the intervention plan.
• Identify progress (made or not).
• Understand the client’s understanding and motivation.
• Recognize repeated discrepancies between the client's reports and observations.
• Consider other intervention options or relevant follow-up resources.
• Identify new situations.

In this section, outline the intervention plan and any steps in the client’s treatment, including:

• Follow-up on the intervention plan (objectives, means, etc.)
• Modifications to the intervention plan
• Individualized service plan
• Requests for consultation or referral to other professionals
• Interventions performed or techniques used
• Intervention report
• Follow-up appointments to add to the record
• Date of the next appointment

Download our free PDF template to start using the SOAP notes template in your clinical note-taking.

SOAP Note Examples

Below are examples of SOAP notes in various clinical contexts. Please note that these are for illustrative purposes only and should not be used for actual clinical documentation.

SOAP Note Example for Mental Health Counselling

In mental health counseling, SOAP notes can help document client sessions and track progress, especially with regard to a client's mental health status and treatment plan.

Client reports feeling overwhelmed with work and personal stressors. He describes feeling anxious most of the time and having difficulty sleeping. Client reports increased irritability and difficulty concentrating.

Client's affect is anxious. He appears tense and fidgety during the session. Client's speech is rapid, and he often interrupts himself. Client's body language suggests discomfort.

Client presents with symptoms consistent with generalized anxiety disorder (GAD). Client's symptoms are significantly impacting his daily functioning and well-being. Differential diagnosis includes adjustment disorder with anxiety.

• Continue weekly counselling sessions to address anxiety symptoms and coping strategies.
• Discuss stress management techniques, including mindfulness and relaxation exercises.
• Refer client to doctor for evaluation and possible medication management.
• Schedule follow-up appointment in one week to monitor progress and adjust treatment plan as needed.

SOAP Note Example for Occupational Therapy

SOAP notes offer a structured approach to documenting client assessments, interventions, and outcomes for occupational therapists. They help facilitate effective communication among healthcare professionals and ensure comprehensive client care.

Client reports increased difficulty in performing activities of daily living (ADLs) due to pain and stiffness in the right shoulder. Client states that the pain has been present for the past month and has worsened over time. Pain is rated as 6/10 on the visual analog scale (VAS).

• Observation: Client demonstrates guarding of the right shoulder and limited range of motion during shoulder abduction and flexion.
• Range of motion: Right shoulder abduction limited to 90 degrees, flexion limited to 100 degrees.
• Strength: Weakness noted in the right shoulder, particularly in abduction and flexion.
• Palpation: Tenderness and palpable stiffness noted in the right shoulder joint.

Client presents with symptoms consistent with adhesive capsulitis (frozen shoulder) of the right shoulder. Pain and stiffness are significantly impacting the client's ability to perform ADLs independently.

• Begin treatment with modalities to reduce pain and inflammation, such as ice and ultrasound therapy.
• Initiate a home exercise program focused on improving range of motion and strength in the right shoulder.
• Educate client on activity modification and ergonomic principles to prevent exacerbation of symptoms.
• Schedule weekly occupational therapy sessions to monitor progress and adjust treatment plan as needed.

SOAP Note Example for Social Work

Here is an example demonstrating how social workers can use SOAP notes to document client interactions, interventions, and assess needs. In this context, SOAP notes help track progress, facilitate collaboration with other professionals, and ensure effective care.

Client reports feeling overwhelmed with financial stressors. She recently lost her job and is struggling to make ends meet. Client expresses feelings of shame and embarrassment about her current situation.

• Observation: Client appears anxious and restless during the session. She avoids eye contact and fidgets with her hands.
• Housing: Client is currently living in a shelter and is concerned about finding stable housing.
• Support system: Client reports limited support from family and friends.

Client presents with acute stress related to recent job loss and financial instability. Client's feelings of shame and embarrassment are impacting her self-esteem and ability to seek help.

• Provide crisis intervention to address immediate needs, including connecting client with resources for food, housing, and financial assistance.
• Develop a safety plan with client to address feelings of hopelessness and suicidal ideation.
• Refer client to a support group for individuals experiencing similar challenges.

How to write SOAP notes with Psylio

Psylio is a comprehensive recordkeeping platform designed to streamline note-taking, client appointments, and financial management. With built-in templates, such as the SOAP notes template, using Psylio can help you save time and simplify your workflow.

To access the SOAP note template directly integrated into your client progress notes:

A SOAP note is one of several models used in clinical note-taking. And while writing progress notes can be tedious, it's a crucial part of the clinical process.

Using templates based on your preferred models makes progress notes easier to create and ensures standardization across all your notes and among the various professionals in an organization.

Whether you use the templates directly within the Psylio platform or save our free PDF for later use, having access to these tools can free up more time for what matters most - your clients!

About the author

Sophie excels as a French and English content specialist and project coordinator for Optania. With a Bachelor of Arts and a double major in French and English literature, her linguistic expertise brings rigour and excellence to the content produced by the team.

Her experience in coordinating content writing, conducting specialized demonstrations and training, and supporting customer service operations demonstrates her continued commitment. Her passion for language and creating quality content is a constant source of motivation in her work.

Share this post!

Latest stories, your guide to effective darp notes (with pdf template).

Thursday, May 30, 2024

Wednesday, March 06, 2024

Explicit Teaching in Individual Intervention

Tuesday, October 10, 2023

Resources & Support

Psylio is not only a recordkeeping platform, it is also a community of highly engaged professionals where sharing and mutual assistance is put forward!

Professional Toolbox

We offer easy and centralized access to various documents, tools and resources for both work and intervention.

A private community to share and help each other

Join a community of passionate and committed professionals. Regardless of your practice environment and clientele, you will undoubtedly benefit from the group’s richness.

Focus on the essentials: your customers

Compliance and documentation

How to write soap notes.

Here’s how SOAP notes can help you write better, faster notes — and effectively document your work as a clinician.

Writing in a journal is easy: There are no rules, and it’s only for yourself. But progress notes come with a different kind of pressure. 

While it might be intimidating to translate your care into a note, it’s simpler than it seems. Especially when you’re using a template like a SOAP note.

What is a SOAP note?

SOAP notes are a specific format for writing progress notes as a behavioral health clinician. They contain four primary sections, represented by its acronym: Subjective, Objective, Assessment, and Plan.

If you’re using a SOAP note template and filling out every section as directed, you should feel good about how your notes stack up to compliance expectations . Each section of a SOAP note is designed to help you document the most critical aspects of your session for compliance with insurance billing, including elements of a mental status exam and risk assessments.

A SOAP note’s holistic approach naturally encourages you as a provider to collect comprehensive insight about your client and their treatment. And because SOAP notes are widely recognized and used in many different healthcare settings, other care providers can easily recognize and review your mental healthcare records to provide continuity of care for your clients. 

Headway’s built-in note template uses the SOAP note format, and includes one-click check boxes to help you fulfill the mental status exam and risk assessment on your notes. 

As you sit down to write a SOAP note, reflect on your session and allow the four sections of the note template to guide you to document the most important aspects of your client’s current state and the progression of your treatment . 

1. Subjective

The subjective section is where you document what your client is telling you about how they feel, their perceptions, and the symptoms.

It’s most important to document the things that relate to the client’s diagnosis. “For example, if your client is depressed, what’s telling you that they’re depressed?,” says Natalia Tague, LPC and Headway’s Clinical Engagement Lead. “The subjective section might include that the client says they've been crying every day, that they can't sleep, or that they've lost their appetite.”

Many providers elect to include a direct quote from the client in the subjective section of their SOAP notes, which helps demonstrate to insurers that the session was unique and veritable.

2. Objective

The objective section should include the therapist's observations, including measurable, observable data.

Consider what you’re seeing in the session that reflects what’s going on with the client in that moment. 

“Literally: What are you seeing?,” says Natalia. “It’s things like: My patient's crying while we speak, they have trouble making eye contact, they seem disheveled, or they look like they haven't showered in a few days.”

3. Assessment

The assessment is the therapist's professional evaluation of the client’s condition, as captured in the subjective and objective sections. It should include their diagnosis, progress, risk assessment, formulation of the situation, and a review of the treatment plan.

In other words: This is where you should sum up the first two sections into a consideration of what’s going on with your client overall.

“The assessment is really just: What’s happening here?,” says Natalia. “What is all of this telling you about the bigger picture: Are they getting better? Are they getting worse? Has there been a drastic change?”

The plan section is where you document your intended actions moving forward. It includes treatment strategies, therapeutic goals, recommended interventions, and any necessary adjustments to the client's treatment plan.

It’s the future-looking piece of the care puzzle: The client has told you what’s going on. You’ve said what you’re observing. You put those two together into an assessment. And now it’s time to plan for the care you want to provide in future sessions.

“You might write that we’re going to meet weekly. Or we’re going to move to meet monthly because they seem to be doing okay. Another part of it might be saying: I think we need to process more of these triggers and build out some coping strategies,” says Natalia. “So the plan is just: Based on your assessment, where do you want to go next?”

SOAP note example

It’s important that SOAP notes, or notes in any template style follow the requirements of a progress note , such as including session details like the start and stop time and place of service.

Client Full Name: Connor Client Client Date of Birth: 2/2/1992 Date of Service: 7/10/2023 Exact start time and end time: 1:33 pm – 2:30 pm: 57 mins Session Location: 123 Serenity Lane, Miami, FL 33143 Diagnosis: (F32.1) Major depressive disorder, single episode, moderate) Subjective: During the session, the client, Connor, reported a significant improvement in his overall mood since our last meeting. He has been consistently utilizing coping mechanisms that were previously discussed and has been making an effort to engage in activities that he once found enjoyable. He expressed that his depressive symptoms have decreased in both intensity and frequency. Additionally, Connor mentioned a recent family gathering where he felt more engaged and connected with his loved ones. This positive experience provided him with a sense of social support, which he believes contributed to his improved mood. However, Connor expressed ongoing concerns about his sleep patterns, noting occasional difficulty falling asleep and early awakenings. Objective: Since our last session, Connor does not present a risk to self or others. His affect during the session was brighter and more animated compared to prior meetings. He actively participated in the session, showing improved eye contact and verbal expression. His body language suggested a decrease in overall tension compared to previous sessions. Connor's energy levels have improved, and he reported engaging in physical activities such as walking and jogging on a regular basis. His mood was calm, and his affect was appropriate for the course of the session. Assessment: Based on today's session, it is clear that Connor has made significant progress in managing his depressive symptoms. The combination of psychoeducation on coping strategies and increased engagement in pleasurable activities seems to be contributing positively to his overall well-being. His affect, mood, and verbal expression have all improved, indicating a positive response to therapy. However, Connor's ongoing concerns regarding his sleep patterns warrant further exploration. His difficulty falling asleep and early morning awakenings may indicate the presence of underlying stressors, which need to be identified and addressed. Plan: Moving forward, we will continue to reinforce and build upon effective coping strategies, such as mindfulness and behavioral activation. Additional attention will be given to Connor's sleep disturbances. We will explore potential triggers and stressors contributing to these issues and provide psychoeducation on sleep hygiene and relaxation techniques. The development of additional relaxation techniques to address his sleep concerns will also be considered. Connor's progress thus far is promising, and continued therapy sessions will aim to further improve his mood, manage his depressive symptoms, and address his sleep concerns.

This document is intended for educational purposes only. Examples are for purposes of illustration only. It is designed to facilitate compliance with payer requirements and applicable law, but please note that the applicable laws and requirements vary from payer to payer and state to state. Please check with your legal counsel or state licensing board for specific requirements.

Tips for writing SOAP notes

• A good rule of thumb is to plan for 5 to 7 minutes to write your progress notes. Try to fit them in between sessions as you’re able, so you don’t end every day with hours of catching up. “Learning how to write concise but accurate notes is such an important skill, just for your own self care as a provider,” says Natalia.
• Comprehensiveness is more important than length. “I’ve seen notes that are literally two sentences per section and they’re great, and then there are notes with four or five sentences for each and they still haven’t covered what they needed to cover,” says Natalia.
• Don’t stress about documenting every single thing that happened in session. For insurance purposes, focus on including the information that supports the client’s diagnosis, and substantiates the ongoing need for treatment and the approach you are using. 

Use Headway’s progress note templates

While there are many options for documentation, Headway's in-product templates are designed to make note-taking fast and efficient, all while helping to take out the guesswork. 

Plus, our templates are included at no additional cost for Headway providers.  

Headway’s team and tools are here to make everything about working with insurance companies (including compliance!) as easy as possible.  

How to write progress notes

Progress notes are the core piece of documentation a mental health care provider should write after each session with a client, but it’s more than just a record of what happened in the session.

Compliance— a Headway Guide

Navigating compliance can be time-consuming and stressful. We’re committed to changing that.

10 insurer requirements commonly missing from notes

Based on our conversations with insurers, here are 10 of the items most commonly missing from charting documentation, including examples of what it takes to meet the requirements for each.

Speech Therapy SOAP Note Templates and Examples

Speech-language pathologists (SLPs) are vital in assessing and treating communication and swallowing disorders. Accurate documentation in speech therapy, such as SOAP notes, is essential for effective treatment planning and progress tracking. These notes serve as a critical communication tool, ensuring that every nuance of a patient's progress is captured and communicated effectively. Their structured format is designed to streamline the complex data that SLPs work with, making the process of speech therapy more transparent and traceable.

Table of Contents

What is a Speech-Language Pathology (SLP) SOAP Note?

How to write clearly & efficiently with the soap format, benefits of the soap format.

• SOAP Note Template
• SOAP Note Examples

Type less. Say more.

Leave boring, repetitive copying & pasting in the past. Share text and images wherever you can type--so you can focus on what matters most.

(No credit card required)

A SOAP note is a widely used method of documentation for healthcare providers. For SLPs, it encompasses a patient’s subjective reports, objective data, an assessment of their condition, and a subsequent treatment plan.

Here are the keys to writing notes using the SOAP format for SLPs:

• Subjective: Document the patient’s subjective impressions of their condition. This includes their personal experiences, feelings, and perspectives related to their speech and language issues.
• Objective: Record observable and measurable data collected during the session. This could encompass clinical measurements, test results, and direct observations of the patient’s speech and language abilities.
• Assessment: Evaluate and summarize the patient’s progress and performance within the session. This is where the SLP synthesizes subjective and objective information to form a clinical judgment about the patient’s current status.
• Plan: Develop a strategic approach for ongoing treatment. This includes outlining therapy goals, determining the frequency of sessions, and planning any home exercises or activities.”

Effective SOAP notes are concise and informative. Here are some tips to write clearly and efficiently:

• Be Succinct: Write short, direct sentences. Use bullet points to list symptoms, observations, and actions.
• Prioritize Information: Start with the most critical information that impacts patient care.
• Use Plain Language: Avoid or explain jargon and technical terms. This makes your notes accessible to all healthcare team members.
• Be Specific: Provide enough detail for others to understand the context. For instance, instead of writing “patient showed improvement,” specify “patient’s stuttering decreased by 10% from the last session.”
• Consistency is Key: Use the same format and order each time you write a SOAP note. This predictability makes it easier to find information.
• Reflect on Objectives: Connect the patient’s progress to the treatment objectives. This shows a trajectory of care.
• Review for Clarity: Before finalizing the note, read it to ensure it’s clear and free of ambiguity or errors.

The SOAP format is not just a procedural tool—it is a strategic approach that offers numerous benefits:

• Enhanced Communication: It promotes clear communication between SLPs and other healthcare providers by using a universal structure.
• Focused Documentation: Each section of a SOAP note serves a distinct purpose, ensuring that documentation is comprehensive yet focused.
• Improved Continuity of Care: Standardized notes make it easier for any practitioner to pick up where another left off, providing continuity in multi-provider settings.
• Efficient Review: The format allows for quick scanning of a patient’s history and therapy progress, which is crucial in time-sensitive clinical environments.
• Goal-Oriented Planning: By clearly outlining assessments and plans, SOAP notes help keep the patient’s therapy goals in focus, ensuring that each session contributes to these objectives.

Speech Therapy SOAP Note Template

Here’s a basic template for an SLP SOAP note:

SOAP Note Template Copy Snippet Copied!

Subjective: – Patient’s reported concerns – Observations about behavior and affect

Objective: – Clinical findings (articulation, fluency, voice, hearing) – Data from the session (error rates, level of assistance needed)

Assessment: – Professional interpretation of objective findings – Progress in comparison to previous sessions

Plan: – Adjustments to therapy objectives – Specific interventions for upcoming sessions – Recommendations for practice at home

Speech Therapy SOAP Note Examples

Using the above template, here are some illustrative examples:

• Subjective: Mr. Thompson, a 58-year-old high school teacher, reports increased difficulty projecting his voice during lectures, causing him to feel fatigued by the end of the day.
• Objective: A voice assessment indicates a 15% reduction in vocal volume and hoarseness post-30 minutes of continuous speaking.
• Assessment: Mr. Thompson demonstrates signs of vocal strain, likely related to voice overuse in a classroom setting, which is exacerbated by inadequate vocal rest and poor hydration.
• Plan: Recommend voice therapy focusing on vocal hygiene and relaxation techniques. Advise a minimum of two therapy sessions per week and regular check-ins with an otolaryngologist. Suggest using a classroom amplifier to reduce strain.
• Subjective: Miss Garcia, a 10-year-old with a repaired cleft palate, expresses frustration with classmates having difficulty understanding her speech, particularly during group activities.
• Objective: Articulation assessment reveals compensatory articulation strategies leading to reduced intelligibility, especially for fricative and affricate sounds.
• Assessment: Despite Miss Garcia’s previous progress, residual articulation challenges continue to affect her speech intelligibility and social interactions at school.
• Plan: Plan to enhance articulation therapy with a focus on fricatives and affricates, utilizing visual aids and tactile feedback. Engage in peer-group activities to improve communicative confidence. Schedule sessions twice a week with additional at-home exercises.
• Subjective: Mr. Jenkins, a 72-year-old retiree with recent left hemisphere stroke, reports frustration with word-finding difficulties and his inability to communicate effectively with his family.
• Objective: During a structured naming task, Mr. Jenkins exhibited a 40% occurrence of anomia, with circumlocution observed during conversation.
• Assessment: Mr. Jenkins’ aphasia impacts his expressive language abilities, contributing to communication deficits that affect his daily interactions and quality of life.
• Plan: Initiate intensive aphasia therapy focusing on naming exercises and functional communication strategies. Incorporate family education sessions for communication partner strategies. Schedule therapy four times per week and provide a list of daily exercises to encourage language retrieval practice.

These examples incorporate specific patient details that provide a clearer picture of individual challenges and tailored therapy plans, demonstrating the personalized nature of speech therapy treatment.

The value of the SOAP note in speech therapy extends far beyond the bounds of routine documentation. The SOAP note is an indispensable tool for SLPs, supporting precise documentation and efficient communication among healthcare providers, thereby ensuring quality patient care.

What is TextExpander

With TextExpander, you can store and quickly expand full email templates, Slack messages, and more anywhere you type. That means no more misspellings, no need to memorize complex instructions, or type the same things over and over again. See for yourself here:

Not able to play the video? Click here to watch the video

Try it for yourself

With TextExpander, you can store and quickly expand full email templates, email addresses, and more anywhere you type. That means you’ll never have to misspell, memorize, or type the same things over and over again.

First, select a snippet you would like to try

Next, type this shortcut below: SOAP SNE1 SNE2 SNE3

Stop typing the same thing over and over again.

With TextExpander, you can easily create custom snippets just like this.

Free for 30 days

Work smarter.

With TextExpander, you can store and quickly expand snippets anywhere you type. That means you'll never have to misspell, memorize, or type the same things over and over, ever again.

Related templates

New patient email templates.

As a medical customer service agent, creating a positive first impression is invaluable. In this article, we present five new patient email templates. These templates will help you communicate effectively with your new patients.

Patient Appointment Email

Effective communication is vital in healthcare and appointment confirmation emails is a key responsibility. In this article are five templates helping streamline communication and enhance patient-provider relationships.

Patient First Billing Email

Providing exceptional customer service is more crucial than ever. In this article, we'll explore the essential elements of crafting compassionate, clear, and effective billing emails that prioritize patient satisfaction.

Less Repetition, More Customer Delight

TextExpander gives your team the power to do what they do best — faster.

Stop repetitive typing

With TextExpander, you can fly through repetitive tasks quickly by expanding the messages your team types regularly w/ just a few keystrokes.

• Create, share, and edit snippets of repetitive text
• Customize and optimize your snippets across teams
• Respond quickly and effectively from any platform
• Reduce burnout, onboard quickly, and ensure team alignment

(No credit card required / Free for 30 days)

• Start Free Trial
• Learning Center
• Getting Started
• Troubleshooting
• Public Groups
• Recruitment
• Customer Support
• Development
• About TextExpander
• Partner with TextExpander

© 2024 TextExpander, Inc. TextExpander is a registered trademark.