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How To Improve Your Speech Therapy SOAP Notes

If you’ve ever moved to a different speech therapy practice, or read another speech therapist’s SOAP notes, you’ll know exactly what we’re talking about when we say everyone does them differently. It’s easy to fall down a rabbit hole trying to work out the best approach and that inevitably leads to feelings of overwhelm.

So, let’s take a step back for a moment. If you start by looking at the purpose of SOAP notes for speech therapy, it’s easier to stay focused on writing value-adding information. You might be writing so many notes that you’ve forgotten why they’re so important. SOAP notes are invaluable for informing caregivers and other therapists about your client and their journey. They are also often needed for reimbursement from medical insurance companies, and will form an important part of your defence if you are reviewed by your profession’s board or involved in a lawsuit.

While everyone has their own approach, reviewing our top nine tips for documenting your sessions could offer some insights to help to refine your note-taking (and you might even find some important time-saving tips that will improve your efficiency!)

What are SOAP Notes?

SOAP is an acronym that refers to a style of note-taking that is widely used by healthcare professionals around the world. They’re written in the past tense and should be focused, informative, and brief.

SOAP stands for:

Subjective

These are your impressions of the client supported by facts that you have observed including feelings, performance, and interactions. This section should include any comments, concerns, or queries raised by your client or their caregiver.

Avoid statements that you can’t support with facts. Only include relevant information that covers your client’s mood, motivation, and willingness to participate in the session.

Objective

Here you will document the measurable outcomes of your client’s performance. This may include any goals that are achieved, scores, and other quantitative information.

You should avoid general statements that you can’t support with data. And don’t go into too much detail when describing the activities in the session.

Assessment

In the assessment section, you will document your interpretation of the session, your client’s progress, as well as their strengths and areas for improvement. You should also compare their performance in this session to previous appointments.

This information should be different to what you’ve covered in the Subjective and Objective sections. Rather, it’s a chance to take a step back and assess whether they are making progress and if there are factors that might be impacting this progress.

Plan

In this last section, you need to outline the next steps in the treatment, and changes you are making to the program. You don’t need to re-work the entire treatment plan in this section because your client’s goals have already been defined. Instead, it’s an opportunity to identify the immediate next steps to take to move your client closer to their goals.

With that outline in mind, let’s take a look at the top nine tips that are going to have the most significant impact on the quality of your SOAP notes:

1. Use a Template That is Focused on Client Outcomes

To get the best results from your sessions, it’s important to set specific goals for each client. These goals should meet the SMART criteria of being Specific, Measurable, Attainable, Relevant, and Time-Based, and should be a mix of short-term and long-term goals.

Let’s get practical:

A good way to ensure the focus stays on the client’s goals, while effectively documenting your sessions, is to use a SOAP template. A quick web search will return plenty of different templates that can be adapted to your specific needs and approach.

Following a template is going to keep you on track, organised and help you stay focused on your clients, even if you have a full schedule of clients. It will also prevent extra thinking work where you’re constantly having to check whether you’ve covered all the necessary information. That thought space can then be redirected into improving the quality of your observations and ensuring that your note-taking is accurate.

2. Always, Always Take SOAP Notes

It’s important to write up your notes for each session. You’ll need to avoid generic, vague reports that don’t give specific insights into your clients and their progress. Remember, these notes may be needed in the event of a board review, medical insurance query, or legal issue. They should cover your client’s goals, and how their treatment is progressing with clear justification for any activities, additional treatments, or interventions.

Let’s get practical:

Practice management software (like Power Diary) comes with a wide selection of SOAP note templates for speech therapists that can be used as-is or customised to reflect the specific needs of your practice. You can quickly add custom fields, including text boxes, checkboxes, and more, allowing you to tailor your template to match your responses, services, and your clients.

3. Find the Right Time to Write Your Notes

While you can’t write up your SOAP notes for speech therapy during a session, you don’t want to put it off for too long either. If you can, get into the habit of writing up your notes immediately after a session to ensure that all the important details are still fresh in your mind. But equally, writing up all your notes from your clients at the end of the day can also work. Whatever you choose, don’t wait too long as the more time that passes after a session, the less you will be able to remember. This might mean that you forget important details, or get one client’s case mixed up with another’s. Falling behind with your notes will increase the time before you are reimbursed for the treatment (if it is covered by medical insurance) and, if your notes pile up, it makes it more and more difficult to get started.

Let’s get practical:

Try different options such as scheduling in time after each appointment, writing up your morning’s notes during your lunch break, or grouping the day’s clients together and writing up your SOAP notes for speech therapy before you leave the office. When you’ve found a time that works well for you, find ways to make sure you can stick to it. This might mean setting an alarm as a reminder, forcing yourself to stay at the office to get them done before you leave for the day, or incentivising yourself with a treat once your day’s SOAP notes are up-to-date.

4. Make Sure Your Notes Are Easy to Understand

Whether you’re taking hand-written or electronic notes, it can be easy to get into bad habits. You need to ensure that your notes are consistent with the requirements of your practice and that you don’t use abbreviations that are different to what is generally accepted in your field.

If you are taking hand-written notes, you should take special care that they are structured clearly and are easy to read, even if someone is just skimming through them quickly. Remember that SOAP notes are not just for your benefit; there are caregivers and other health professionals that will need to be able to read your notes.

Let’s get practical:

Of course, first prize is to take your notes online and use a template. But if that’s not an option for you (or you love your own handwriting), it might help to get some feedback. Share your notes with colleagues and find out whether they find your structure easy to follow, if the template you’re using is comprehensive and flows well, and if they find the experience of reviewing your notes more difficult than electronic notes.

5. Include the Right Information

When it comes to SOAP notes, there’s a delicate balance between including all the important information and excluding unnecessary information, and it can be difficult to get it right.

It’s a given that you need to document each individual session as it provides evidence supporting the quality and efficacy of your sessions. If you regularly forget or omit important details, this can create questions in the minds of those who review your notes, be it other health professionals, medical insurance companies, or caregivers. Therefore, the more details you can include, the better. A reasonable level of detail will improve the quality of your treatment as you can stay consistent with your methods and monitor the results. This will also help others who need access to your notes.

But on the other hand, the flip side of the coin is important too! In order to get your SOAP notes right, you need to exclude unnecessary information as well. Information that doesn’t add value makes your notes harder for others to use, takes you a lot longer to complete, and makes the whole process more burdensome. In general, SOAP notes should not be longer than one to two pages for each session, and each of the sections should contain one to two paragraphs.

Let’s get practical:

To ensure that your SOAP notes are comprehensive but not overwhelming, you can:

  • Focus on improving your writing, so you don’t overcompensate by writing more.
  • Have a clear idea of what information needs to be included for your treatment plan.
  • Limit your notes to under two pages.
  • Have an understanding of what other parties expect from your notes, including those responsible for settling your accounts, colleagues in your practice, and other health professionals.

6. Use Speech Therapy Documentation Software

If you’re still relying on handwritten SOAP notes, it might be time for a change. Using speech therapy documentation software such as Power Diary’s powerful, customisable treatment note templates is a game-changer. You can access pre-built templates that are going to make your note-taking easier (and more effective), and they can all be quickly adapted if there are different fields that you want to have available.

Not sure what all the fuss is about? Electronic SOAP notes are:

  • Flexible and versatile, they can be customised to your exact needs.
  • Easy to share, other medical professionals can quickly review your notes (and they’re always legible!)
  • Easy to duplicate – you can start from a copy of your last session notes to save even more time.
  • Completely secure – using practice management software for your SOAP notes means that you can leverage their high levels of security and IT best practices.

Let’s get practical:

Electronic SOAP notes for speech therapy will help you track client goals and improvements. The flexible functionality offered by Power Diary makes it quick: you can choose from options including text areas, tick boxes, multiple choice boxes, and more. You can also create different template variations for different types of sessions – eg a first session, assessment, etc. Read how a cloud-based system (or going paperless) helped Smart Talk Therapy Speech Pathology to grow to 15 practitioners and 3 clinics within 3 years.

7. Always Check Your SOAP Notes for Speech Therapy

When you’re finishing up your notes, before you sign off, take a moment to check them against a template (and your clinical guidelines). It’s incredibly frustrating to have billing claims denied simply because you forgot to include a section.

Let’s get practical:

This is where electronic SOAP note templates are in a class of their own. Working from a pre-existing template with all the necessary sections already added means that you’ll be sure to include everything you need. They will help you define what services you’re billing for and will make sure that all the necessary information has been documented accurately.

8. Use the Right Language

One thing that all speech therapists will agree on is the importance of using action words, especially if you are submitting claims to insurance companies. There are many online action word cheat sheets that are specifically tailored to speech therapy SOAP notes (like this one that’s available for free). Incorporating the right action words will:

  • Speed up your note-taking process;
  • Assist with documenting your specialist services;
  • Illustrate challenges, progress, and goals accurately and in detail;
  • Add value to those reading your notes;
  • Ensure you are providing clear, concise documentation;
  • Improve your remuneration rates.

Let’s get practical:

Useful action words for speech therapists include: monitored, observed, prompted, addressed, clarified, demonstrated, and evaluated (there are many, many more).

9. Keep Learning from Others

The best way to do this will depend on whether you are a sole practitioner or working in a practice with other speech therapists.

Let’s get practical:

If you work with other speech therapists, particularly those who have more experience, ask for their advice. Share your SOAP notes with them and request feedback, ask if you can have a look at theirs and see what they’re doing differently, or organise a training session on SOAP notes so that everyone can benefit.

If you work as a sole practitioner, this can be a bit more difficult. It can work well to meet up with other practice owners, or speech therapists in your network to sharpen your skills. You can ask them to review your note-taking and suggest improvements, or keep the discussion more general and share SOAP note experiences to discover what’s working and what isn’t. And there’s always the internet. If you’re looking for great examples to learn from, a quick web search will turn up sample SOAP notes for speech therapists that you can then adapt to your needs. These examples will give you a structure and flow that you can use to inform your own note-taking.

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Ultimately, better SOAP notes for speech therapy will reduce claim denials, improve the effectiveness of your therapy, and allow for easier cooperation between other health professionals who work with your clients. They will also give you more confidence in the work that you’re doing, increase your job satisfaction, and ensure that you are protected in the event of a dispute.

If you’re working as a speech therapist and have found this helpful, please pass it on to your colleagues and other speech therapists in your network. There is not a lot of training or open discussion on how to take SOAP notes properly, so the more we can support each other to improve in this important area, the better.


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