Anyone want to learn how to write SLP SOAP notes better and faster? Me, please! I’ve just finished researching and writing a guide for writing SOAP notes for SLPs to help me be more succinct and faster with my documentation. I’ve included verb banks, sentence starters, and example statements. The handout has already helped me, and I hope it helps you, too!
Free DIRECT download: SLP SOAP Note Guide – cheat sheet. (Email subscribers get free access to all the resources in the Free Subscription Library.)
Outline:
- SLP SOAP Note Guide: Why now and how?
- Subjective.
- Objective.
- Assessment.
- Plan.
- Takeway advice.
- Related Eat, Speak, & Think posts.
- Selected references.
SLP SOAP Note Guide: Why now and how?
I love my job. The paperwork? Not so much. My goal is to improve my charting skills so that I don’t waste time on it. I bet some of you can relate!
Long story short? I realized I was repeating the same information in multiple parts of the same session note. Some of that might be unavoidable, but some of it was on me. I didn’t have a clear framework for what information belonged in each section.
I thought I knew.
After all, it’s right in the name: Subjective, Objective, Assessment, Plan (SOAP).
In tackling this project, I learned that I was not clear on the distinction between Objective and Assessment. I was also including elements of Objective and Assessment under Subjective. And my Plan wasn’t specific enough.
That lack of clarity led me to repeat myself multiple times in the note, which was frustrating for me.
And because I wasn’t writing clear Objective and Assessment statements, I tended to narrate just about everything that occurred during the session. Because, “If you don’t document it, it didn’t happen.”
So, I researched documentation requirements and used my notes and materials from various documentation training courses to create a draft cheat sheet.
Then I spent many hours running my ideas and examples through ChatGPT, getting feedback on where I was unclear, exploring alternate wording, and getting additional suggestions. I evaluated every suggestion critically and refined the examples until they reflected how we actually document in practice. The result is the SOAP note guide below.
Subjective
What is the patient reporting? What is the context for today’s appointment?
The purpose of the Subjective section of a SOAP note is to report the patient’s current status and the context for today’s appointment. Save clinical observations and interpretation for later sections.
We should include our patient’s report on any changes in medical status, notable events, and how they are feeling. Include their update on our goals, including any progress they’ve made or any challenges they’ve run into.
Be sure to include the context. Why is this appointment happening? Why you? Why now? Here we should document the reason for today’s appointment.
Sentence starters:
- Patient reports…
- Patient states…
- Patient’s spouse describes…
- Patient seen today for…
Example statements:
- Patient reports “I’m eating better, except the soup choked me last night.”
- Patient states that he attempted using visualization to remember the name of the physical therapy assistant, but “I still can’t remember her name.”
- Patient’s spouse describes patient “frowning and throwing up his hands” when he “gets stuck on a word.”
- Patient seen today for skilled intervention related to dysphagia secondary to CVA.
Objective
What happened during the session?
The Objective section describes observable activity and performance. The information documented here could be verified by an observer.
Objective includes:
- Tasks completed
- Modifications implemented
- Cueing provided
- Conditions affecting performance
- Measurable patient response
Clinical reasoning is not explained here. At most, it is implied through observable actions.
Helpful verbs
- Achieved
- Attempted
- Completed
- Demonstrated
- Engaged in
- Faded
- Implemented
- Increased
- Initiated
- Maintained
- Performed
- Practiced
- Produced
- Provided
- Reduced
- Repeated
- Responded
- Required
- Utilized
Sentence starters:
- SLP implemented…
- Patient completed…
- SLP provided…
- Patient demonstrated…
- Patient required…
Example statements
- SLP reduced task complexity following increased errors during divided attention task.
- Patient achieved 80% accuracy across 10 structured naming trials, independently using printed alphabet to self-cue.
- Patient maintained use of chin-tuck posture during 9/10 thin liquid trials.
- Patient produced four complete sentences during picture description task with spouse implementing Response Elaboration Treatment strategies.
- Patient initially required step-by-step instructions to add an appointment to digital calendar, but by the end of the session, he was able to add one appointment independently.
Assessment
What does today’s session mean for the patient’s progress toward their therapy goals?
In the Assessment section, we explain why skilled SLP involvement was required for this session. At a minimum, the note should document at least one form of skilled clinical reasoning.
Four types of skilled clinical reasoning may be documented here:
- Clinical interpretation: What does today’s performance reveal about our patient’s current abilities and limitations?
- Clinical decision-making: What decisions guided today’s therapy session?
- Intervention design & structuring: How was the intervention deliberately constructed to support learning and carryover?
- Functional & prognostic reasoning: What does today’s performance imply for safety, independence, carryover, or progression?
In practice, we often blend two or more types of clinical reasoning into a short statement. For clarity, I’m discussing each one separately, and then I’ll provide more comprehensive examples.
Clinical interpretation
What does today’s session reveal about our patient’s current abilities and limitations?
Clinical interpretation involves differential reasoning, identifying underlying causes or contributing factors, characterizing observations, synthesizing subjective and objective data, and making informed inferences.
- Analyzed
- Assessed
- Attributed
- Characterized
- Clarified
- Concluded
- Correlated
- Differentiated between
- Discerned
- Discriminated
- Distinguished
- Evaluated
- Inferred
- Integrated
- Interpreted
- Judged
- Synthesized
Sentence starters:
- SLP inferred from error patterns that…
- SLP differentiated between ___ and ___ based on…
- SLP evaluated patient performance and determined that…
- SLP discerned a pattern of ___ across tasks, suggesting…
- Based on patient’s response to ___, SLP judged that…
Example statements:
- SLP interpreted inconsistent word-retrieval errors as reflective of impaired semantic access rather than motor speech impairment.
- SLP attributed observed breakdowns during divided attention tasks to reduced working memory capacity rather than lack of effort.
- Patient performance was characterized by reduced initiation and prolonged response latency across structured and functional tasks.
- SLP synthesized patient report, caregiver input, and task performance to identify a pattern of cognitive fatigue impacting late-session accuracy.
- Dynamic assessment clarified that naming accuracy improved with phonemic cueing, indicating preserved phonological processing.
The examples above interpret patient performance without describing clinical decisions.
Clinical decision-making
What clinical decisions guided today’s therapy session?
Clinical decision-making includes the choices we make about intervention type, instructional method, strategy selection, prioritization of therapy targets, pacing, intensity, environmental setup, care partner involvement, education focus, progression or continuation of task difficulty, and goal modification.
Helpful verbs:
- Advanced
- Balanced
- Chose
- Deferred
- Determined (necessity of)
- Established
- Identified
- Justified
- Limited
- Prioritized
- Ruled out
- Selected
- Weighed
Sentence starters:
- SLP selected this treatment approach due to…
- Treatment focus was prioritized toward ___ because…
- SLP balanced competing task demands to support…
- SLP determined that intervention was necessary because…
- SLP deferred progression to ___ due to…
Example statements:
- SLP selected errorless learning with spaced retrieval as an instructional approach due to decline in patient performance when cues were faded.
- Treatment focus was balanced between impairment-based drills and functional communication tasks to promote skill acquisition while supporting generalization.
- SLP balanced task complexity with patient endurance to promote skill acquisition without exacerbating cognitive fatigue.
- SLP ruled out increasing task complexity at this time due to persistent breakdowns under divided attention conditions.
- SLP determined that additional care partner training was necessary due to limited strategy carryover outside of structured activities.
Intervention design & structuring
How was the intervention deliberately constructed to support learning and carryover?
Intervention design and structuring describes how therapy activities are deliberately constructed to support learning, strategy use, and carryover. This may include task selection, task modification, sequencing of tasks, cueing strategy or level of support, scaffolding or grading of support, and environment conditions.
- Aligned
- Calibrated
- Designed
- Devised
- Formulated
- Graded
- Individualized
- Layered
- Mapped
- Organized
- Outlined
- Scaffolded
- Sequenced
- Structured
- Tailored
Sentence starters:
- SLP structured intervention to…
- Therapy activities were organized to…
- SLP scaffolded support within the task to…
- Intervention was calibrated to…
- SLP aligned task demands with patient’s current abilities to…
Example statements:
- SLP designed therapy tasks to isolate word retrieval while minimizing competing attentional demands.
- Task difficulty was graded to incrementally increase cognitive load while maintaining patient engagement.
- SLP layered semantic and phonemic supports within the activity to promote accuracy while encouraging independent initiation.
- Intervention was sequenced from structured drill practice to conversational application to support generalization of trained strategies.
- Intervention was tailored to incorporate patient-preferred vocabulary and personally-relevant scenarios to improve participation in conversation with family.
Functional & prognostic reasoning
What does today’s performance imply for safety, independence, carryover, or progression?
In this form of reasoning, we connect present data to future function, safety, or independence. For example, we may anticipate difficulty with functional tasks, highlight safety implications, discuss readiness for progression, estimate treatment needs, and project trajectory.
Helpful verbs and verb phrases:
- Anticipate
- Consider implications for
- Determine appropriateness of progression to
- Determine readiness for
- Estimate
- Forecast
- Identify barriers to
- Predict
- Project
- Recognize risk for
Sentence starters:
- SLP identifies barriers to…
- SLP determines patient is now ready to begin…
- SLP predicts that…
- SLP recognizes risk for…
- SLP projects need for…
Example statements
- SLP anticipates difficulty with independent appointment scheduling given persistent breakdown when multiple steps are presented verbally.
- SLP considers implications for safe community mobility given inconsistent use of compensatory strategies in distracting environments.
- SLP determines appropriateness of progression to higher-level discourse tasks based on sustained accuracy during structured language activities.
- SLP estimates that additional structured practice will be required before reliable carryover to home routines is achieved.
- Based on current performance patterns, SLP forecasts gradual improvement in functional communication with continued strategy training.
Comprehensive assessment statements
What does today’s session mean for the patient’s progress toward their therapy goals?
I separated out four types of clinical reasoning (above), to highlight the different types of assessment statements we can write. However, in clinical practice, we often blend two or more types of clinical reasoning into a short statement.
Clinical interpretation + decision making + intervention design:
- SLP interpreted inconsistent word retrieval errors as reflective of semantic access rather than motor speech impairment. Based on this pattern, SLP selected semantic feature analysis as the primary intervention approach and used structured tasks to isolate word retrieval while minimizing competing attentional demands.
- SLP synthesized patient report, caregiver input, and task performance to identify cognitive fatigue contributing to performance breakdowns. Treatment tasks were therefore structured to alternate between high-demand activities and supported practice to maintain engagement and promote strategy use.
Clinical interpretation + decision making + functional/prognostic reasoning:
- Observed breakdowns during multi-step tasks were attributed to reduced working memory capacity rather than lack of effort. SLP determined that additional care partner training was necessary to support strategy implementation during daily routines and recognizes ongoing risk for communication breakdown in complex situations.
- Dynamic assessment revealed improved naming accuracy when phonemic cueing was provided, indicating relatively-preserved phonological processing. SLP therefore prioritized cueing-based intervention approaches and anticipates improved functional communication with continued strategy training.
Clinical interpretation + intervention design + functional/prognostic reasoning:
- Patient demonstrated improved accuracy when task complexity was reduced and visual supports were introduced. SLP therefore structured intervention to scaffold strategy use within functional communication tasks and anticipates gradual improvement in independent message formulation with continued practice.
- Patient demonstrated improved carryover of use of chin tuck strategy for thin liquids when spaced retrieval with errorless learning was introduced. SLP therefore structured intervention to incorporate care partner cueing and anticipates improved strategy use during meals.
Plan
What are the next steps in therapy based on today’s session?
In the Plan section, we describe the next steps in therapy based on today’s session. This may include modifying the intervention approach, introducing new targets or goals, collaborating with care partners or other team members, or planning activities to support carryover and generalization.
Helpful verbs:
- Advance
- Adjust
- Continue
- Coordinate
- Expand
- Focus
- Incorporate
- Introduce
- Modify
- Monitor
- Progress
- Provide
- Recommend
- Reinforce
- Review
Sentence starters:
- SLP will continue intervention targeting…
- Treatment will progress to…
- Next session will focus on…
- SLP will introduce…
- Care partner will demonstrate…
Example statements:
- SLP will adjust task complexity to support consistent use of training word-finding strategies during conversation.
- Treatment will advance to multi-step functional tasks to support carryover of memory strategies during daily routines.
- SLP will coordinate with care partner to train the use of environment supports for medication management.
- Therapy activities will expand to include telephone-based activities to support generalization of communication strategies.
- SLP will provide therapeutic assessment of patient’s use of compensatory strategies during a snack or meal to determine readiness to advance diet.
Takeaway advice
I’ve been using a draft version of the SLP SOAP Note Guide for a couple of weeks, and it has already helped me. So here is my suggestion:
- Print out the PDF handout.
- For the next few sessions, read the key information for each element of SOAP as you write that section.
- If you’re having trouble thinking of what to say, check out the sentence starters for ideas.
If you find a mistake or have a suggestion, please let me know!
Feel free to share the PDF with your SLP friends and colleagues!
Related Eat, Speak, & Think posts
- How to document a skilled dysarthria session.
- Writing SMART memory goals for a reluctant patient.
- An easy way to write participation-level speech therapy goals.
Selected References
- Krafft, C., & Kornetti, D. (n.d.). Defensible documentation in home health: Care planning & goal setting [Online course]. Medbridge. https://www.medbridge.com/educate/courses/defensible-documentation-in-home-health-care-planning-goal-setting-cindy-krafft-and-dee-kornetti
- Strunk, E. R., & McCarthy, M. (n.d.). Fundamental concepts of defensible documentation [Online course]. MedBridge. https://www.medbridge.com/educate/courses/fundamental-concepts-defensible-documentation-maureen-mccarthy-ellen-strunk
Free DIRECT download: SLP SOAP Note Guide – cheat sheet. (Email subscribers get free access to all the resources in the Free Subscription Library.)
Featured image by Karola G from Pexels, found on Canva.com.
Lisa earned her M.A. in Speech-Language Pathology from the University of Maryland, College Park and her M.A. in Linguistics from the University of California, San Diego.
She participated in research studies with the National Institute on Deafness and other Communication Disorders (NIDCD) and the University of Maryland in the areas of aphasia, Parkinson’s Disease, epilepsy, and fluency disorders.
Lisa has been working as a medical speech-language pathologist since 2008. She has a strong passion for evidence-based assessment and therapy, having earned five ASHA Awards for Professional Participation in Continuing Education.
She launched EatSpeakThink.com in June 2018 to help other clinicians be more successful working in home health, as well as to provide strategies and resources to people living with problems eating, speaking, or thinking.
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