November 2017

National Therapy Center Speech Therapy • Occupational Therapy • ABA Therapy

Where did the session occur: home, daycare, etc.

Who was present during the session: Mom, BCBA, etc.

Subjective information: include anything the caregivers may have said that happened earlier in the day or could affect therapy (ex: Client woke up at 3:00 am and didn’t go back to sleep), subjective observations (ex: client appeared tired)

Data: ◦ Frequencies: independent-12, prompted-15 ◦ Accuracies: compliance-88% ◦ Duration: tantrum-20 minutes ◦ ABC data for any new behaviors

Strategies: ◦ Used to teach skills: specific prompting methods ◦ Antecedent & consequence interventions

Specific targets: ◦ Hand washing task analysis: turning off water

Common errors of incorrect responding: ◦ Discriminating how are you vs. how old are you

Anything that may change for the next session ◦ Programming updates needed

Overall plan of care ◦ ABA services should continue for X hours/week to

work on the following domains (e.g. communication, adaptive, etc.

“Homework”/strategy to be implemented by caregivers outside of sessions ◦ Anytime client throws an item he should be given a

direction to pick the item up

Use 3rd person: e.g. client, he/she, they, etc. ◦ If referring to yourself, refer to yourself as BT/RBT

rather than “I”

“Serviced”: cars are serviced, people “provide services”

Client’s name (not DC EI): if needing to refer to specific people use general information, “client”-rather than client’s initials, Mom, sister, peer, etc. ◦ DC EI: write client’s name specifically (e.g. David)

specific to EI audience

State specifically what occurred rather than your interpretations ◦ “Didn’t want to do much” vs. when presented a

direction client did not make any attempts to perform the direction

Detail information: specific behaviors that occurred ◦ Challenging behaviors: dropping-1, hitting-5, etc.

Check for grammar mistakes ◦ Beginning letter of sentence should be capitalized!

Double check spelling ◦ Reread to see if there were any incorrect auto

spelling corrections

Writing style formal (this is not a text nor it is a written version of a conversation!) ◦ Avoid abbreviations

◦ Need punctuation, capital letters, etc.

This should describe HOW (e.g. implementation) goals were worked on, not just what was worked on for the session duration

Prompting methods: time-delay, textual, etc. List strategies used: ◦ Antecedent: Presented with visual schedule at the

beginning of the session to transition activities ◦ Consequence (RBT): RBT did not respond or give

client access to item when screaming for toy ◦ Consequence (Caregiver): Mom told client to use

their inside voice

What to AVOID… What to say instead…

Having a tough time

Needed help

Shut down

Didn’t listen

Seemed frustrated

Required

Engaged in the following challenging behaviors: hitting, crying, etc.

Responded incorrectly, did not attempt to respond independently

Crossed his arms & put head down over arms

Continued engaging in spitting

Following an incorrect response, threw materials off the table

Provided

Make sure the following is included: ◦ Data

◦ Strategies-is sufficient information provided?

◦ Objective language

◦ Names

◦ Spelling & grammar

◦ Signature

National Therapy Center National Speech/Language Therapy Center, Inc. SPEECH THERAPY • OCCUPATIONAL THERAPY • ABA THERAPY

SH

412 First St. SE

Rear Building, Lower Level

Washington, DC 20003

Phone: 202.470.4185

Fax: 202.741.9952

•

5606 Shields Dr.

Bethesda, MD 20817

Phone: 301.493.0023

Fax: 301.493.8230

•

20400 Observation Dr. Ste. 104

Germantown, MD 20876

Phone: 301.540.0445

Fax: 301.540.0766

•

1934 Old Gallows Rd. Ste. 350

Tysons Corner, VA 22182

Phone: 301.493.0023

Fax: 301.493.8230

•

1100 N. Glebe Rd. Ste. 1010

Arlington, VA 22201

Phone: 301.493.0023

Fax: 301.493.8230

How to Complete a SOAP Note

S Subjective/Setting: describe the environment the session took place in (e.g. home, daycare, etc.). With describing the environment also list who was present during the session (e.g. Mom, BCBA, etc.). Include anything the caregivers may have said that happened earlier in the day or could affect therapy, such as client woke up at 3:00 am and didn’t go back to sleep. Example: Session was held at client’s daycare. Daycare staff & peers were present throughout the session duration. Client smiled and greeted therapist on arrival and initiated requesting for toys. Activities included: breakfast, circle time, centers (e.g. puzzles, dramatic play, etc.).

O/A

Objective/Assessment: Data (e.g. frequencies, accuracies, duration, ABC for any new behaviors, etc.). Include strategies that were used to teach skills as well (if applicable) according to the current BIP (antecedent and/or consequence interventions). Include prompting methods, specific targets and what errors may have led to incorrect responding. Example: Mand: I-40 P-75 Tact: 80%. Partial verbal prompts required for incorrect responses. Errors included non-responses. Echoic: B-20% T-0% Washing hands: 5/10 target-turning off water Behavior reduction: aggression-3, tantrum-25 minutes Visual schedule used to prompt appropriate transitions to replace challenging behaviors. Partial physical prompting and redirection provided when challenging behaviors occurred.

P Plan/Progress: Anything that may change for the next session or the overall plan of care. This is where you include information for the BCBA to make any programming updates. You can also recommend strategies, or “homework” to be implemented by caregivers when therapists are not present. Examples: Client’s mom told therapist she will be having speech on Wednesdays and needs to change ABA schedule. A change should be considered for the washing hands TA, client can’t reach the soap and therefore can’t complete step 6.