Individual Workshop Assignment SOAP (1)

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University of North Texas *

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3010

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Psychology

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Feb 20, 2024

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Individual Workshop Assignment 4: Writing SOAP Notes 25 points Task: Identify each section below as a section of a S-O-A-P note. - Subjective (S) - Objective (O) - Assessment (A) - Plan (P) 1. Improvement observed in word retrieval and writing activities. Auditory comprehension remains at low level. Commands may be too hard or clinician’s presentation may be too fast. Pace of session good. 2. The client appeared very alert and cooperative. He stated, “I’m ready to work hard today.” 3. Continue working on final consonants and structured speech activities. Begin to fade all cueing during /s/ activity to see if successful production can be maintained. 4. Client arrived on time and appeared ready and motivated to begin therapy. 5. Client performed fluency retrials during a two-minute monologue at 40% accuracy. Client demonstrated 66% accuracy for using pull-outs during a two-minute conversation. 6. Client read a rehearsed 6 th grade level passage with 55/56 phrases read fluently at 98% accuracy with a clinician model and self-corrections. 7. Continue to fade cueing when appropriate while working with the AAC device. Provide homework that targets word lists on AAC device with specific prompts and practice with motor speech targets. 8. Client demonstrated successful production of /s/ phoneme in the final position when imitating a direct model from the clinician. Client’s tongue movements demonstrated fatigue by the end of the session but was able to be corrected with minimal verbal cueing. 9. Client demonstrated independent use of a self-rating scale during the structured tasks. He verbalized being happy with his improved tinnitus rating when using the self-rating scale. Client demonstrated improved performance since using the self-practice of speech targets outside of therapy. 10. Client correctly produced 79/85 real words with initial /r/ following a direct model and 6/85 real words with initial /r/ following a direct model with additional verbal cueing to correct tongue placement. 11. Begin to work on simple sentences/phrases with /ts/ blends. Provide verbal feedback and instructions to parent to carryover activities to the home environment.

Individual Workshop Assignment 4: Writing SOAP Notes 25 points 12. Encourage client to continue to increase oral reading outside of therapy. Continue to monitor speech errors during unstructured conversation. 13. Client met all goals during the session. She produced an increased amount of language in the form of jargon throughout play activities and showed an increase in labeling toys and other materials. She independently stated each activity of the session using a visual schedule. 14. Client’s mother reported she was excited to return to speech therapy. Client actively participated in therapy activities at the beginning of the session. 15. The client’s accuracy answering inference questions increased from 90% to 100% from questions answered in previous sessions. Reading fluency remained consistent with previous passage read with clinician model. 16. Client correctly produced 8/8 (100%) of expressive language target words following a direct model from the clinician. 17. Continue to target turn-taking and consistency of eye contact during unstructured conversation using outlined pragmatic strategies, measured using a self-rating scale. Assign homework of conversation with familiar communication partner to facilitate generalization. 18. Client showed an increase in independent monitoring volume of voice production as evidenced by a decreased need for verbal cueing from the clinician. Client met all set goals for the session. 19. Client demonstrated a positive transference of skills when reading personal materials and using strategies discussed in therapy sessions. 20. Client appropriately asked 4/5 (80%) of rehearsed questions when communicating with an unfamiliar conversation partner with minimal cueing from the clinician in this session, which is 3 consecutive sessions. 21. John appeared alert today. He greeted the clinician with a smile. 22. Continue use of science experiments to increase Eric’s use of spontaneous expressive utterances. Continue to target auxiliary verbs using book reading activities and decrease amount of scaffolding given. Prepare home program to be completed over spring break to decrease regression over break. 23. (a) Production of /r/ increased from 65% accuracy during the last session to 90% accuracy during today’s session. (b) Withdrawal of visual models resulted in a decrease in accurate production of single syllable words from 90% to 65%.

Individual Workshop Assignment 4: Writing SOAP Notes 25 points 24. Client continues to demonstrate difficulty distinguishing between core repetition and retrials. Also, he may be observing retrials but not signaling consistently. Pull-outs on fixations met target criteria, pull-outs on laryngeal closures did not. 25. Produced final consonants at sentence level with 85% accuracy during a structured activity. Produced /s/ in all positions during conversational speech with minimal auditory cueing.

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