The attached file has the assignment, read the file with the assignment and fill out the SOAP note.Also attached is a good example you can use as a reference or guide.
soap_assignment.docx
soap_note.docx
good_example_soap.docx
Unformatted Attachment Preview
Using the provided SOAP form template, write a SOAP note based on the following
scenario. As this is just a scenario, be creative in what you might add to each section of
the SOAP note. Points are dependent on including the correct type of information within
each section of the SOAP (subjective, objective, assessment, plan). Refer to the power
point and class discussion for additional information about documentation.
The patient goals are included for you to reference.
Fred Smith is a 72 year old male that has been attending the MSUM outMr. Smith clinic since
July, 2017. He attends therapy sessions twice per week on a consistent basis. Mr. Smith had a
stroke in November, 2016 and has received intermittent speech therapy services since that
time. Mr. Smith is a retired school teacher and continues to work part-time in a local grocery
store. Mr. Smith continues to be active in the community and frequently joins friends for
concerts, dinners, and fitness classes. Mr. Smith was initially referred for difficulties with word
retrieval, related to his diagnosis of Broca’s aphasia following his stroke.
Following are a list of his current goals:
1. Mr. Smith will follow multi-step commands with 90% accuracy and verbal cues in order to
understand directions during complex activities within 4 weeks.
2. Mr. Smith will accurately participate within conversation with 90% accuracy and verbal cues
and visual cues in order to understand directions during complex activities within 3 weeks.
3. Mr. Smith will improve reading comprehension of sentences to 95% accuracy with verbal
cues and visual cues in order to use symbol identification for comprehension of information
within 4 weeks.
4. Mr. Smith will improve ability to name pictures to 85% accuracy and minimal Visual Cues in
order to improve expressive language skills and communicate complex needs/wants within 4
weeks.
5. Mr. Smith will improve word finding for generative naming to 85% accuracy and minimal
descriptive cues in order to improve expressive language skills and verbalize choices in
everyday activities within 3 weeks.
Name:
Age:
DOB:
Gender:
Ordering Physician:
Insurance:
Primary Diagnosis (Speech-Language
Pathology): (Description and ICD-10 code)
Secondary Diagnosis (Secondary):
(Description and ICD-10 code)
Date of Service:
Time: (00:00 to 00:00 provide in 24 hour time)
S:
O:
A:
P:
Charges: (Description and CPT code)
________________________ ________
YOUR SIGNATURE/ TITLE
DATE
Minnesota State University Moorhead is an equal opportunity educator and employer. This document can be made available in alternative formats by
calling 218.477.2652 (V/TTY). For TTY communication, contact the Minnesota Relay Service at 1.800.627.3529.
Last name, first name
Date: 06/07/2018
Time In: 10:00 am
Medical Record #:
DOB: 04/18/1971
Out: 10:50 am
Provider: POK Speech-Language Hearing Clinic
Location: POK Speech Clinic – 11
Treating Therapist: Luther, Jill – CCC-SLP
Start of Care Date: 03/01/2017
Diagnoses & Billing Codes
ICD Code
Onset
10
R48.8
06/01/2015 Other symbolic dysfunctions
10
I69.120 06/01/2015 Aphasia following nontraumatic intracerebral hemorrhage
Code
Diagnosis
Description
92507 Speech / Hearing Therapy
Min/Qty
Units
N/A
1
Subjective
CLIENT arrived on time for his session today. Baseline data was collected during today’s session. CLIENT utilized 1-2 word utterances
during most of today’s session. CLIENT generally did not initiate conversation during today’s session. However, with verbal prompts
and time, CLIENT is able to participate actively in conversations in a non-distracting environment such as the therapy room. CLIENT
displayed verbal signs of frustration when he was not able to word-find when conversing with the clinician. However, CLIENT displayed
a friendly and positive affect throughout the session. CLIENT reported no changes to medication or any pain.
Objective
Goals:
– Short Term: Started: 10/03/2017 Recorded: 7x
CLIENT will generatively name 11 items in a specified category with minimal semantic cues from clinician in 2 minutes across three
consecutive sessions. Cues are defined as: minimum= 0-2 verbal prompts, moderate= 3-6 verbal prompts, maximum= 7+ verbal
prompts.
Notes: The clinician did not utilize cuing when collecting baseline data regarding this goal. CLIENT was able to independently name
7 fruit items in two minutes, 10 colors in two minutes, and 4 car parts in two minutes.
– Short Term: Started: 10/03/2017 Recorded: 75%
CLIENT will write the name or function phrase of an item after hearing a verbal description and will achieve 80% accuracy of spelling
with moderate cues across three therapy sessions as measured by the clinician.
Notes: After hearing a verbal description, CLIENT named and independently spelled the name of an item with 50% accuracy (2/4
charted opportunities). This increased to 75% accuracy (3/4 charted opportunities) when given mod cues from the clinician (e.g.,
providing him with the initial “g” sound for the word “gas”).
– Short Term: Started: 10/03/2017 Recorded: 64.7%
CLIENT will independently use correct motor sequencing when producing his scripts with 90% accuracy as judged by the clinician
over three therapy sessions.
Notes: CLIENT was able to independently recite script 1 with 75% accuracy (3/4 lines) script 2 with 50% accuracy (2/4 lines), script 3
with 50% accuracy (2/4 lines), and script 4 with 80% accuracy (4/5 lines). CLIENT made self-corrections throughout reading the
scripts, self-corrections were marked as correct. The clinician observed that CLIENT had frequent difficulty with producing the word
Report Created with Fusion Web Clinic (TM)
Page 1
“have” in scripts 3 and 4.
– Short Term: Started: 01/15/2018 Recorded: 100%
When provided with a word and written cues (“I like..” “I don’t like..” and “I have…”, etc.) CLIENT will produce a phrase in 90% of
opportunities as judged by the clinician over three consecutive session.
Notes: CLIENT was able to independently produce 100% of phrases (7/7 attempts) when provided with the written cues “I like…”, “I
don’t like…”, and “I have…”.
– Short Term: Started: 03/14/2018 Recorded: 4.3x
CLIENT will increase his use of content words to describe situation-based pictures from a baseline of 1 word to an average of 5
words per picture.
Notes: CLIENT was able to independently use 7 content words when describing a picture of people tubing, 2 words when describing
a picture of people waiting in line, 2 words when describing a beach volleyball scene, and 6 words when describing a picture of a
man spilling coffee on himself. His independent use of content words averaged to 4.3 words per picture. However, when provided
with moderate cuing, CLIENT was able to use an average of 5.8 content words per picture (e.g., the clinician asking what the
volleyball players are standing on).
Assessment
During the categorical naming activity, CLIENT named some items that did not belong in a certain category (e.g., “wine” for the colors
category). CLIENT also unintentionally perseverated on using the term “raspberry” while thinking of items in the “colors” and “car parts”
categories after he used the term in the “fruit” category. Moderate cuing was needed in 2/4 description labelling opportunities. However,
more baseline data collection regarding this goal should be conducted. CLIENT had difficulty with producing the word “have” while
reading scripts 3 and 4. The clinician should assess the level of cuing necessary for successful productions of the scripts during the
next session as well as asking probe questions to elicit natural use of the scripts (e.g., “How old are you?”). CLIENT did well with
constructing phrases when provided with a visual cue. The clinician should provide CLIENT with different, and possibly more complex
visual cues to elicit more complex and unfamiliar responses. In the final picture description activity, CLIENT did well with producing
most content words independently. However, CLIENT used some content words that were irrelevant to the picture being described
(e.g., “vest” when nobody in the scene was wearing a vest). CLIENT benefitted from being provided moderate verbal context cues (e.g.,
“Where is this man?”).
Plan
During the next session, the clinician will continue collecting baseline data regarding CLIENT’s current objectives (i.e., categorical
naming, writing labels when provided with a description, producing a phrase with visual cues, and using content words when describing
a situation-based picture). However, the clinician should probe CLIENT to determine the amount of cuing that is necessary for
successful productions.
Signatures
Signed On:
06/07/2018
Contributor:
State License #:
Report Created with Fusion Web Clinic (TM)
Signed On:
06/07/2018
Therapist: Luther, Jill – CCC-SLP
State License #: 8580
Page 2
…
Purchase answer to see full
attachment
