SLPA 5701: Documentation of Therapy Progress Flashcards

This set of flashcards covers the fundamentals of therapy documentation, the SOAP note format, and setting-specific requirements for clinicians.

Documentation

An essential part of the therapy process used for data-driven decisions and reimbursement; follows the principle: 'If you didn't document it, it didn't happen.'

SOAP Form

The most commonly used format for therapy documentation, consisting of Subjective, Objective, Assessment, and Plan sections.

Subjective (S)

The section of a SOAP note containing information about the experiences, views, or feelings of the patient or caregiver, such as the client's cooperativeness and arrival time.

Objective (O)

The section of a SOAP note that includes numerical data from the session, such as accuracy percentages and cueing levels (e.g., $80\%$ accuracy with min cues).

Assessment (A)

The interpretation of objective and subjective data, such as noting if performance decreased due to a change in stimuli or if a goal met criteria for consecutive sessions.

Plan (P)

The section stating the strategy for future sessions, including goal updates, continuing therapy, or upcoming evaluations like the GFTA-3.

EMR System

Electronic Medical Record system; frequently used in hospital settings for recording brief 'daily notes' with drop-down boxes.

University Clinic Documentation

Often more in-depth documentation that utilizes a formal SOAP format following every session.

Response to Intervention (RTI)

A framework in school systems where data is often taken each session with progress reports provided every few weeks.

Private Practice Documentation

A setting where the format is up to the owner, but daily notes are recommended to assist with insurance billing and documented history.

Discharge Form

A specific report type required in hospital settings upon the conclusion of services.

IEP

Individualized Education Program; a specific report type required within the school system.

Progress Reports

Clinical documents used in university clinics and schools to summarize advancement over a period of time.

Confidentiality Limit

The principle that SOAP notes and clinical documentation are not private and may be released to others.

GFTA-3

A specific evaluation tool mentioned as part of a therapy plan to be administered in a future session.

STG

Short-term goal; used in the Objective section to track specific targets like producing /f/ or /l/ with specific accuracy thresholds (e.g., $80\%$).