Biola MSLP 530 Notes: Session Planning, Data Collection, and SOAP Notes

Maslow's Hierarchy of Needs

• All behavior communicates!! (Key principle emphasized in the presentation)

• Hierarchy (bottom to top):

  • Physiological needs: food, water, warmth, rest; basic biological requirements

  • Safety needs: security, safety, predictable environment; known expectations, schedule, rules/agreements; trust; therapist presence and safe space

  • Belongingness and Love needs: rapport, learning names, remembering facts, making the client feel seen

  • Esteem needs: prestige, feeling of accomplishment; verbal feedback and celebratory input

  • Self-actualization: achieving one's full potential, including creative activities

• Overview of how the hierarchy applies to therapy sessions (ensure lower-level needs are met before addressing higher-level goals)

• Visual cues from slides:

  • Physiological → Safety → Belongingness/Love → Esteem → Self-actualization

Maslow’s Hierarchy of Needs in Detail

• Page 5: Physiological Needs specifics include: $ext{Food/Water}, ext{Pain}, ext{Temperature}, ext{Comfort}, ext{Distractions}, ext{Energy/consciousness levels}, ext{Sensory needs}$

• Page 6: Safety Needs specifics include: known expectations, schedule, rules/agreements, trust; match energy and adjust; confident therapy room presence; safe space; emotionally, socially, physically safe

• Page 7: Belonging and Love Needs specifics include: rapport; learn names; remember facts; see the client

• Page 8: Esteem Needs specifics include: provide verbal feedback; celebrate small accomplishments; provide appropriate, celebratory input

• Page 9: Self-actualization specifics include: empower clients to communicate; provide client-based intervention; explain the importance of the work being done

• Page 10: Before seeing a client, review each level of the pyramid to ensure lower needs are met

• Page 11: Reflective prompt: Think about where your child was on this list; consider what could have been happening

• Page 12: Learning objectives after the presentation (overview): describe difference between treatment vs session plan; importance of a thoughtful session plan; develop a Biola Session Plan; determine cueing strategies; distinguish homework vs generalization activities

Provide Choices for the child. Don’t give a no, yes option if you do not want a no as an answer. Ask questions that give options that matter

BE funny if you have to, light hearted , but always be respectful of the child's feelings and experiences. This will help in creating a comfortable environment where they feel safe to express themselves.

Redirection, have them do somtehting different

Creating a Session Plan: Core Concepts

• Purpose: map what you hope to accomplish in a session; a template helps organize goals, cues, tasks, and adjustments

• Distinctions:

  • Treatment Plan: long-term plan for treating a disorder over the course of intervention (example: phonological approach for Bethany’s speech sound disorder; Johnny seen 2 times/week for 50 minutes; TX plans documented in the assessment report)

  • Session Plan: a plan for what you hope to accomplish during a particular session; new session plan for each session based on progress

• Session Plan template availability: Biola University CSDS webpage; download before proceeding

Session Plan: Step-by-Step

Step 1 — Identify Client Information

• Fill in client information on the template

• C.A. = chronological age; used for clients born premature and under 48 months

• Omit “MedicalDx” if there is no medical condition associated with the communication disorder

• My example fields (from slides):

  • Client: Johnny Smith

  • Clinician: Sara Speech

  • Birthday: 10/15/2005

  • Age/C.A.: $7 ext{-}3$

  • Semester Goals: 1. 2. 3.

  • Session Goals: include 1) "do" statement, 2) "condition", 3) "criterion", & 4) "assistance" level

• Additional header info: Biola Speech and Language Clinic; Cognitive-Communicative Diagnosis: Expressive language and phonological delay; Date of Session: tomorrow; Session #: 4

Step 2 — Long-Term Goals (LTG)

• Insert Long Term goals; create 3 LTGs and place on the Session Plan

• Example LTGs from slides:

  • By December $2015$, Johnny will use /k/ in all word positions in conversation with no cues at $90\%$ accuracy as measured by SLP

  • By December $2015$, Johnny will use descriptor + object name to accurately name objects during play with no cues at $80\%$ accuracy as measured by SLP

  • By December $2015$, Johnny will use he and she pronouns in conversation with no cues at $90\%$ accuracy as measured by SLP

• LTGs should align with the cognitive-communicative diagnosis and inform Semester Goals

Step 3 — Session Goals

• Write 3 session goals that align with LTGs; each goal should be a complete statement starting with: "By the end of the session, the client will…"

• Structure for each Session Goal: include 1) "do" statement, 2) "condition", 3) "criterion", 4) "assistance level"

• Example (from slides):

  1. By $December$ 2015, Johnny will use /k/ in the initial word position in sentences with no cues with $90\%$ accuracy as measured by SLP

  2. By $December$ 2015, Johnny will use descriptor + object name to accurately name objects during play with no cues at $80\%$ accuracy as measured by SLP

  3. By $December$ 2015, Johnny will use he and she pronouns in conversation with no cues at $90\%$ accuracy as measured by SLP

• The Example shows aiming for a lower-level performance for Session Goals vs LTGs, to reflect progress throughout the session

Step 4 — Lesson Plan (Methods & Materials, Tasks, Cues, Adjustments)

• For each Session Goal, list:

  • Methods & Materials (e.g., Silly Stories with /k/ cards, car wash color labeling, fishing for cards for pronouns)

  • Cue To Be Used (e.g., tactile, visual, verbal cues; e.g., tongue depressor, mirror, color wall, etc.)

  • Adjustments in Tasks (If task too hard or too easy) with concrete changes (e.g., reduce cards, or add /k/ final position cards)

• Example entries (from slide 29):
  1) Goal 1: /k/ in initial position; Lesson: Review tongue placement; Materials: /k/ picture cards; Cue: tactile (tongue depressor), Visual (mirror)
  2) Goal 2: Color descriptors for naming objects; Lesson: Cars/wash activity; Cue: visual (colored paper); Verbal cue to name color; Adjustments: adjust color set if too hard/easy
  3) Goal 3: He/She pronouns; Lesson: Fishing for cards; Cue: visual of boy/girl labels; Adjustments: pair cards as needed

• Important: The cueing strategies are explicit per target; document them for each goal

Step 5 — Cues

• Indicate specific cues for each target and be as concrete as possible (avoid vague terms)

• Examples from slides:

  • Visual cues: picture cards, colored walls, demonstration cards

  • Verbal cues: prompts or phrases; model expansion

  • Tactile cues: tongue depressor for /k/

• Rationale: Build a toolkit of cues to help the client meet session goals; anticipate multiple cues for flexibility

Step 6 — Adjustments to Tasks

• Plan adjustments to increase or decrease task difficulty without changing cues

• Examples:

  • If task too hard: reduce the number of cards or simplify stimuli

  • If task too easy: increase difficulty (e.g., extra cards with /k/ in final position, more complex objects)

  • If too hard: pair cards to provide context (e.g., He/She pairing)

• Important: Adjustments should NOT involve adding or removing cues

Step 7 — HomeWork and Generalization (H&G)

• Determine one homework and one generalization activity for the client; not required for all three targets

• Rule of thumb: Do not assign homework for skills the client is <75\% accurate in clinic

• Homework: concrete practice (speech cards, worksheets, apps) for skills near mastery

• Generalization: practice in natural contexts or different settings

• Example (from slides):

  • Homework: /k/ speech cards

  • Generalization: Johnny should bring 3 red, 3 blue, and 3 green objects to speech next week

• The slide emphasizes documenting H&G clearly for family understanding

Data Collection & SOAP Notes: Overview

Data Collection: Purpose and Process

• Purpose: 1) measure progress, 2) document efficacy, 3) maximize clinician effectiveness

• Process steps (from slide 41):

  • Pre-Tx information

  • Choose Tx targets

  • Determine baseline

  • Write goals

  • Session planning and implementation

  • Determine teaching methods

  • Develop scaffolding strategies

  • Create Tx activities

  • Develop generalization plan

  • Session documentation

  • Data collection

  • Write SOAP notes

  • Write progress note

  • Treatment flowchart

Types of Data

• A. Quantitative Measures: expressed in numbers; determine if enough to meet session, STG, and LTG goals

• B. Qualitative Measures: descriptive; what cues were provided, contexts

Strategies for Collecting Data

• Create a probe to check at the end of a treatment segment

• Create a chart/score sheet for quick tallying

• Qualitative data should be described shortly after the session

• If data is collected by families, be clear about input expectations

Data Collection Across Sessions

• Data can be collected on every session goal after practice on that goal

• Structure per target:

  • Session target 1: Teach → Practice → Measure target 1

  • Session target 2: Teach → Practice → Measure target 2

  • Session target 3: Teach → Practice → Measure target 3

• Then write SOAP notes for the session

SOAP Notes: Structure and Content

What is SOAP?

• Data during the session is reported in SOAP notes; used to document progress; part of legal medical/educational record

• Structure: Subjective, Objective, Analysis, Plan (and sometimes additional details depending on setting)

• Sign and date the entry

Subjective (S)

• Non-measurable information; includes:

  • History

  • Family reports of concerns/frustrations

  • Family updates on progress

  • Participation in therapy

  • Other observations (home life, mood, etc.)

• Example: Parent reports at home frustration when Johnny cannot be understood; balance difficulties observed (falling from chair, etc.)

Objective (O)

• Measurable findings; report session goals and data; qualitative measures may be described if helpful

• Examples (from slides):

  • G1: J will use velars in single words with no cues; 50\% accurate

  • Note: production was exaggerated

  • G2: J will use /s/ blends in initial position in sentences; 90\% accurate; no cues

Analysis (A)

• Combines S and O to form progress summary

• Example: G1 increasing velars, still deliberate but improving; G2 ready to move into conversation

Plan (P)

• Next steps and actions:

  • G1: velars in single words; emphasize soft touch

  • G2: /s/ blends in conversation; continue practice

  • Advise parents on strategies to manage frustration due to unintelligibility

  • Consult with PT regarding balance issues

Additional SOAP Details

• Sign and Date at the bottom to prevent post-entry edits

• Differences across facilities: SOAP vs other session notes; essential elements remain: session goals, measurement, observations, feedback and concerns

Recap: What to Document and Why

• Clear differentiation between treatment plans and session plans; ensure alignment of LTG, LT goals, and session goals

• Use concrete cueing strategies and task adjustments to support progress

• Systematic data collection (quantitative and qualitative) to demonstrate progress and guide future decisions

• SOAP notes provide a structured, legally relevant record of progress, goals, and next steps; include subjective observations, objective measurements, analysis linking the two, and actionable plans

• Always include goals, measurement data, observations, family concerns, and any health/motivation observations

Key References from Slides (Biola CSDS Context)

• Session Plan template availability and use on Biola University CSDS webpage

• Biola Speech and Language Clinic sample client data (example: Johnny Smith; Age/CA $7 ext{-}3$; Session #: $4$)

• Emphasis on aligning session goals with semester LT goals and using the Biola Session Plan template throughout

• Reiteration: Before starting therapy, review Maslow’s levels to ensure lower needs are addressed; links to client readiness and engagement