Soap Speech Pathology Clinic Note Short Note PDF

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Speech Pathology Clinic Note

Client Name: Abigail Date of Service (DOS): 2/1/2016 Time of Service (TOS): 8:35-9:35 a.m. Clinician: Susie S. Subjective: Abigail was seen for an individual, speech-language therapy session at Mrs. Stewart’s Private Speech Therapy Clinic. She entered her session excited and ready for the day. Abigail worked diligently and cooperated with the clinician’s directions. The session took place at a table in a classroom. Abigail had a great session. Objective: 1. Expressive language, use of past-tense verbs: (2/4) 50% accuracy. Abigail told a story about a family trip to Yellowstone. Additional work is needed. Continue to target this objective. 2. Expressive language, use of irregular plural nouns: (1/3) 33% accuracy. Additional work is needed. Continue to target this objective. 3. Articulation, production of /r/ in single syllables with a pause: (14/20) 70% accuracy. Additional work is needed. Continue to target this objective. 4. Articulation, production of /r/ in single syllables without a pause: (13/20) 65% accuracy. Additional work is needed. Continue to target this objective. 5. Articulation, auditory feedback loop for the production of /r/ in single syllables: (8/8) 100% accuracy. Continue to monitor this objective. 6. Articulation, production of “er” in words: (3/3) 100% accuracy. The clinician played a board game with the client to target this objective. Additional work is needed. Continue to monitor this objective **Materials/Tasks: oral narrative, paper, pen, flashcards, board game made by the clinician, timer. Assessment: Abigail had a great session today. She continues to have trouble with past-tense verbs, irregular plural nouns, and producing /r/ in syllables and words. In order to target the objectives listed, additional work is necessary. Abigail has been diagnosed with a speech and language disorder. Plan: Continue with current plan of care (POC). Return to the clinic in 1 week. 010640164 Undergraduate Student-Clinician University of Arkansas...