Clinical Writing and SOAP Notes Overview

Objectives

• Labeling and defining the purposes of professional clinical writing.
• Demonstrating understanding of basic characteristics of professional clinical writing.
• Demonstrating understanding of a SOAP note and its functions.

What is Professional Documentation?

• Written notes performed after any interaction or attempted interaction with the client and their caregiver or family.
• Professional documentation is clinical writing.
• May include:
  • Assessment reports.
  • Therapy encounter notes or SOAP notes.
  • Contact logs.
  • Progress reports.
  • Discharge reports.
  • Goals.
• Does not include:
  • Emails written to the client or the team.
  • Written notes at home with the client or family.
  • Home practice notes or instructions.
  • It is strictly professional writing.

Purpose of Clinical Writing

• For the payer:
  • Evidence of eligibility for skilled service.
  • Evidence of medical or developmental necessity.
  • Identifying the skilled service provided to the client.
  • Important for billing purposes.
• For the client:
  • Supports quality of care.
  • Supports continuity of care.
  • Supports communication with family, team members, and physicians.
  • Should be as precise as possible.
• For the clinician:
  • Ensures professional accountability.
  • Provides protection against liability.
  • Complies with state and federal regulations.
  • Establishes adherence to the standards of practice.
• Identification of the skilled service provided includes documenting:
  • The skilled services provided.
  • Therapy techniques used.
  • Strategies implemented.
• Supporting communication with your team:
  • Important for referencing notes, especially in settings like the Biola Clinic.
  • Helps in understanding the client's history, progress, and future needs.

Importance of Documentation

• If you didn't document it, it didn't happen.
• Documentation is essential for billing and legal purposes.
• Consistent documentation is crucial, but it can be challenging, especially in school settings.

Personal vs. Official Documentation

• Personal Documentation:
  • Personal data sheets for individual note-taking during sessions.
  • Includes notes on areas of improvement and areas needing more focus.
• Official Documentation:
  • Required for billing purposes (e.g., Medi-Cal billing).
  • Parents can choose whether or not to allow their child's name to be included for Medi-Cal billing.
  • Documentation is still necessary even if parents decline, to maintain a professional record.
  • Documents specific therapy details needed for billing and potential collaboration or supervision.

Common Errors in Clinical Writing

• Forgetting to include baseline data for goals.
• Lacking objective data.
• Providing minimal progress details without analysis.
• Failing to summarize services provided.
• Setting goals that are not measurable.
• Using vague or excessive language.
• Using informal language.
• Exhibiting a general lack of organization.

Skilled vs. Unskilled Language

• Skilled Language Examples:
  • Use action-oriented words like analyzing, developing, implementing, modifying, customizing, identifying.
  • Focus on what the SLP and client did.
• Unskilled Language Examples:
  • Avoid vague terms like "did a really good job", "seems to be", or "appears to be".
  • Avoid being too general or subjective.
  • Do not use undefined terms like "maximal prompting" without specifying what that means.
  • Avoid unprofessional language or labeling the client (e.g., "the kid was not cooperative today").
• Objective and Clear Language:
  • Write so that anyone (e.g., parent, teacher, lawyer) can clearly understand what happened during the session.

Personal Pronouns

• Do not use personal pronouns (I, we) in professional documentation.
• Refer to yourself as "the SLP" or "the assessor".

Qualities of Good Clinical Writing

• Clear: Easy to understand.
• Specific: Provides detailed information.
• Objective: Based on facts, not opinions.
• Concise: Brief and to the point.
• Relevant: Includes only information relevant to the client's goals or condition.
• Professional: Maintains a formal and respectful tone.
• Documents skills and interventions provided.

SOAP Notes Overview

• S: Subjective Data/Statements
  • Information influenced by personal feelings, tastes, or opinions.
  • Includes your interpretation of behavior or the client's report.
  • Example: "Rick was engaged during the session and reported completing assigned practice," or "The client entered the Therapy Room and stated he was tired."
• O: Objective Data
  • Hard data, numbers, and percentages.
  • Includes the number of correct responses and the number of trials.
  • Using hard sheets of paper to record data is recommended, especially for clinicians early in their careers.
  • Example: "Scott completed goal one with 50% accuracy independently, increasing to 65% given one verbal cue."
• A: Assessment/Analysis
  • Analysis of the objective data.
  • Documentation of implemented interventions, techniques, and skills taught.
  • Example: "Lauren benefited from verbal cues for accurate lingual placement," or "They require additional prompting for label placement."
• P: Plan
  • What will be done next.
  • Includes the next session's schedule and planned interventions.
  • Example: "Next session is scheduled for [date]. A queuing hierarchy will be implemented to build independence on goal two," or specify goals like "We will work on articulating vocalic r's."