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Top 10 Common Speech Language Pathology SOAP Note Examples

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List of Cases

  1. Childhood Articulation Disorder
  2. Adult Dysphagia
  3. Developmental Language Delay
  4. Stuttering Treatment
  5. Aphasia Rehabilitation
  6. Voice Therapy
  7. Autism Spectrum Communication
  8. Post-Stroke Communication
  9. Cognitive-Communication Disorder
  10. Pediatric Feeding Disorder

1. Childhood Articulation Disorder

Description

Initial evaluation and treatment session for a child presenting with articulation difficulties affecting academic and social communication.

SOAP Note

Client Name: Tommy Chen

Date of Visit: 09/01/2024

Subjective

Tommy Chen, a 5-year-old male, presents for initial speech therapy evaluation due to concerns about articulation errors. Parents report difficulty understanding speech, especially with unfamiliar listeners. Teacher notes reduced class participation. Child shows frustration when not understood. No history of hearing problems or developmental delays. English is primary language at home and school.

Objective

  • Speech Sound Assessment:
    • Goldman-Fristoe Test of Articulation-3: 5th percentile
    • Error patterns: /s/, /r/, /l/ substitutions
    • Consonant clusters reduced
    • Age-inappropriate processes
    • Intelligibility: 65% with unfamiliar listeners
  • Oral Motor Examination:
    • Structure WNL
    • Function adequate
    • Tongue mobility good
    • Dentition age-appropriate
    • No oral habits noted
  • Language Screening:
    • Receptive language age-appropriate
    • Expressive vocabulary adequate
    • Sentence structure intact
    • Following directions: Good
  • Behavioral Observations:
    • Cooperative
    • Good attention span
    • Aware of errors
    • Motivated to improve
    • Parent interaction appropriate

Assessment

  1. Moderate Articulation Disorder
    • Multiple sound errors
    • Age-inappropriate patterns
    • Functional impact
  2. Communication Impact
    • Reduced intelligibility
    • Social interaction affected
    • Academic participation limited
  3. Positive Prognosis
    • Good attention
    • Strong motivation
    • Parent support

Plan

  1. Treatment:

    • 2x weekly sessions
    • Sound production training
    • Phonological awareness
    • CPT Code: 92507

  2. Interventions:

    • Target /s/, /r/ initially
    • Minimal pair activities
    • Sound placement cues
    • Home program development

  3. Parent Education:

    • Carryover activities
    • Progress monitoring
    • Reinforcement strategies
    • Communication tips

  4. Follow-up:

    • Weekly progress notes
    • Parent consultation
    • Teacher collaboration
    • Quarterly review

2. Adult Dysphagia

Description

Evaluation and treatment for post-stroke dysphagia affecting swallowing safety and nutrition.

SOAP Note

Client Name: Robert Thompson

Date of Visit: 09/02/2024

Subjective

Robert Thompson, a 68-year-old male, presents for dysphagia evaluation following left CVA 2 weeks ago. Reports coughing with thin liquids and difficulty managing solid foods. Family notes increased meal times and weight loss (10 lbs in 2 weeks). Currently on mechanical soft diet with honey-thick liquids. Motivated to return to regular diet. No current pneumonia or respiratory issues.

Objective

  • Clinical Swallow Evaluation:
    • Modified Barium Swallow Study completed
    • Delayed pharyngeal swallow
    • Silent aspiration with thin liquids
    • Reduced laryngeal elevation
    • Residue in pyriform sinuses
  • Oral Motor Assessment:
    • Left facial weakness
    • Tongue strength 3/5
    • Labial strength 4/5
    • Oral transit time increased
    • Adequate dentition
  • Functional Measures:
    • FOIS Level 4
    • EAT-10 Score: 18
    • Yale Swallow Protocol: Failed
    • O2 saturation stable
    • Cognitive status intact
  • Current Diet:
    • Mechanical soft
    • Honey-thick liquids
    • Small, frequent meals
    • Oral intake: 75% of needs

Assessment

  1. Moderate-Severe Dysphagia
    • Post-stroke
    • Aspiration risk
    • Nutritional impact
  2. Oral Phase Deficits
    • Reduced strength
    • Prolonged transit
    • Control difficulties
  3. Pharyngeal Phase Impairment
    • Delayed trigger
    • Incomplete clearance
    • Safety concerns

Plan

  1. Treatment:

    • 3x weekly sessions
    • Swallow strengthening
    • Compensatory strategies
    • CPT Code: 92526

  2. Interventions:

    • Thermal-tactile stimulation
    • Mendelsohn maneuver
    • Effortful swallow
    • Diet modifications

  3. Education:

    • Safe swallow strategies
    • Positioning techniques
    • Diet compliance
    • Warning signs

  4. Follow-up:

    • Weekly monitoring
    • Diet advancement
    • Team coordination
    • Progress measures

3. Developmental Language Delay

Description

Evaluation and treatment for a preschool child presenting with significant delays in receptive and expressive language development.

SOAP Note

Client Name: Emily Martinez

Date of Visit: 09/03/2024

Subjective

Emily Martinez, a 3-year-old female, presents for language evaluation following concerns from pediatrician and parents about delayed language development. Parents report limited vocabulary (approximately 20 words), no two-word combinations, and difficulty following directions. Child communicates primarily through gestures and pointing. No concerns with hearing; developmental milestones otherwise appropriate. Family history negative for language disorders.

Objective

  • Language Assessment:
    • PLS-5 Scores:
      • Auditory Comprehension: SS 75 (5th percentile)
      • Expressive Communication: SS 71 (3rd percentile)
      • Total Language: SS 72 (3rd percentile)
    • REEL-4:
      • Receptive: Age equivalent 18 months
      • Expressive: Age equivalent 16 months
  • Communication Sample:
    • MLU: 1.0
    • Vocabulary size: ~20 words
    • No word combinations
    • Limited word types
    • Frequent gestures
  • Play Skills:
    • Functional play present
    • Emerging symbolic play
    • Joint attention intact
    • Turn-taking observed
  • Social Communication:
    • Eye contact appropriate
    • Engagement good
    • Initiates communication
    • Uses gestures effectively

Assessment

  1. Moderate-Severe Language Delay
    • Receptive deficits
    • Expressive deficits
    • Below age expectations
  2. Communication Profile
    • Prelinguistic skills intact
    • Social intent present
    • Gestural communication
  3. Treatment Needs
    • Language stimulation
    • Vocabulary development
    • Early syntax
    • Parent training

Plan

  1. Treatment:

    • 2x weekly sessions
    • Play-based intervention
    • Language facilitation
    • CPT Code: 92507

  2. Interventions:

    • Core vocabulary focus
    • Routine-based learning
    • Visual supports
    • Language modeling

  3. Parent Training:

    • Language stimulation
    • Communication strategies
    • Daily routines
    • Progress monitoring

  4. Follow-up:

    • Weekly documentation
    • Parent consultation
    • Progress review
    • Goals adjustment

4. Stuttering Treatment

Description

Treatment session for an adolescent with persistent developmental stuttering affecting academic and social participation.

SOAP Note

Client Name: Jason Wilson

Date of Visit: 09/04/2024

Subjective

Jason Wilson, a 14-year-old male, presents for ongoing stuttering treatment. Reports increased difficulty with class presentations and social interactions. Describes avoiding specific words and situations. Recently experienced bullying related to speech. Parents note increased anxiety about speaking situations. Currently in 8th grade with good academic performance but reduced verbal participation.

Objective

  • Fluency Assessment:
    • SSI-4 Score: 28 (Moderate)
    • % Syllables Stuttered: 8%
    • Secondary behaviors present
    • Blocks predominant
    • Situation variability noted
  • Speech Sample Analysis:
    • Types of Disfluencies:
      • Blocks: 60%
      • Prolongations: 25%
      • Repetitions: 15%
    • Average duration: 2 seconds
    • Tension level: Moderate
  • OASES-T Results:
    • Impact Score: 3.4 (Moderate-Severe)
    • Quality of life affected
    • Social impact significant
    • Academic concerns noted
  • Coping Strategies:
    • Word substitution frequent
    • Situation avoidance
    • Some self-advocacy
    • Basic techniques used

Assessment

  1. Moderate Stuttering
    • Consistent disfluencies
    • Secondary behaviors
    • Situational variation
  2. Psychosocial Impact
    • Social anxiety
    • Academic effects
    • Self-esteem concerns
  3. Treatment Progress
    • Strategy awareness
    • Variable application
    • Motivation present

Plan

  1. Treatment:

    • Weekly individual sessions
    • Fluency shaping
    • Stuttering modification
    • CPT Code: 92507

  2. Interventions:

    • Easy onset practice
    • Cancellation technique
    • Voluntary stuttering
    • Desensitization activities

  3. Support Services:

    • School consultation
    • Support group referral
    • Counseling components
    • Self-advocacy training

  4. Follow-up:

    • Weekly monitoring
    • Situation hierarchies
    • Goal adjustment
    • Progress tracking

5. Voice Therapy

Description

Treatment session for a professional voice user with muscle tension dysphonia and vocal fatigue affecting occupational performance.

SOAP Note

Client Name: Sarah Anderson

Date of Visit: 09/05/2024

Subjective

Sarah Anderson, a 35-year-old female teacher, presents for ongoing voice therapy. Reports continued vocal fatigue by end of teaching day, though improved from initial presentation. Notes better awareness of vocal hygiene but struggles with consistent implementation during long teaching periods. Describes occasional throat clearing and morning hoarseness. Using amplification system as recommended.

Objective

  • Voice Assessment:
    • CAPE-V Scores:
      • Overall Severity: 35/100
      • Roughness: 30/100
      • Breathiness: 20/100
      • Strain: 40/100
    • VHI-10 Score: 22 (Moderate impact)
    • s/z ratio: 1.3
  • Laryngeal Examination:
    • Visible tension in neck/shoulders
    • Elevated laryngeal position
    • Normal vocal fold closure
    • No lesions observed
  • Voice Parameters:
    • Maximum Phonation Time: 15 seconds
    • Pitch range: 2 octaves
    • Loudness control: Improving
    • Resonance: Slightly pressed
  • Posture/Breathing:
    • Upper chest breathing pattern
    • Forward head posture
    • Shoulder tension present
    • Limited breath support

Assessment

  1. Muscle Tension Dysphonia
    • Moderate severity
    • Occupational impact
    • Improving awareness
  2. Voice Use Patterns
    • Better technique use
    • Inconsistent application
    • Fatigue persists
  3. Treatment Progress
    • Good awareness
    • Technique learning
    • Carryover challenges

Plan

  1. Treatment:

    • Weekly sessions
    • Voice exercises
    • Technique training
    • CPT Code: 92507

  2. Interventions:

    • Resonant voice therapy
    • Breath support training
    • Vocal function exercises
    • Semi-occluded exercises

  3. Education:

    • Vocal hygiene review
    • Workplace strategies
    • Environmental modifications
    • Self-monitoring tools

  4. Follow-up:

    • Weekly monitoring
    • Technique refinement
    • Progress documentation
    • Goal adjustment

6. Aphasia Rehabilitation

Description

Treatment session for an individual with moderate Broca's aphasia following left hemisphere CVA, focusing on functional communication skills.

SOAP Note

Client Name: Robert Thompson

Date of Visit: 09/06/2024

Subjective

Robert Thompson, a 62-year-old male, presents for continued aphasia therapy 6 months post-stroke. Family reports improved ability to express basic needs but continued frustration with complex communication. Patient indicates increased confidence in familiar situations but avoidance of social gatherings. Uses communication book successfully in structured settings.

Objective

  • Language Assessment:
    • WAB-R AQ: 65.2
      • Fluency: 4/10
      • Comprehension: 7.4/10
      • Repetition: 6.5/10
      • Naming: 7.3/10
    • ASHA FACS:
      • Social Communication: 5/7
      • Communication of Basic Needs: 6/7
      • Daily Planning: 4/7
      • Reading/Writing: 3/7
  • Communication Analysis:
    • Agrammatic speech
    • Word-finding difficulties
    • Preserved automatic speech
    • Good gesture use
  • Functional Skills:
    • Phone use: Emerging
    • Reading: Simple text
    • Writing: Single words
    • AAC use: Consistent

Assessment

  1. Moderate Broca's Aphasia
    • Expressive deficits
    • Preserved comprehension
    • Functional progress
  2. Communication Status
    • Basic needs met
    • Social limitations
    • Strategy use improving
  3. Treatment Response
    • Good engagement
    • Strategy learning
    • Functional gains

Plan

  1. Treatment:

    • 2x weekly sessions
    • Functional tasks
    • Communication training
    • CPT Code: 92507

  2. Interventions:

    • Script training
    • Melodic intonation
    • Semantic feature analysis
    • Conversation practice

  3. Support:

    • Family training
    • Community integration
    • Resource connection
    • AAC updates

  4. Follow-up:

    • Progress tracking
    • Goal updates
    • Outcome measures
    • Family consultation

7. Pediatric Feeding Disorder

Description

Treatment session for a toddler with feeding difficulties related to sensory processing and oral motor challenges.

SOAP Note

Client Name: Lucas Chen

Date of Visit: 09/07/2024

Subjective

Lucas Chen, a 2-year-old male, presents for ongoing feeding therapy. Parents report continued selective eating with strong aversion to textured foods. Some improvement noted with acceptance of purees. Family describes mealtime stress and extended feeding duration (>45 minutes). Child demonstrates anxiety with new foods but willing to engage in food play activities.

Objective

  • Feeding Assessment:
    • BAMBI Score: 102
    • Food Inventory:
      • Accepts: 8 foods
      • Tolerates: 12 foods
      • Refuses: Most new foods
    • Meal duration: 45-60 minutes
    • Growth: 15th percentile
  • Oral Motor Skills:
    • Lip closure: Adequate
    • Tongue lateralization: Limited
    • Jaw stability: Fair
    • Chewing pattern: Immature
  • Sensory Processing:
    • Tactile defensiveness
    • Temperature sensitivity
    • Texture aversions
    • Visual acceptance varied
  • Behavioral Observations:
    • Food anxiety present
    • Engagement improving
    • Positive play interaction
    • Gagging reduced

Assessment

  1. Feeding Disorder
    • Sensory-based
    • Oral motor component
    • Behavioral impact
  2. Progress Status
    • Expanding acceptance
    • Reduced anxiety
    • Family stress present
  3. Treatment Response
    • Good engagement
    • Play-based success
    • Gradual progress

Plan

  1. Treatment:

    • 2x weekly sessions
    • Feeding therapy
    • Parent training
    • CPT Code: 92526

  2. Interventions:

    • Food chaining
    • Sensory integration
    • Oral motor exercises
    • Play-based exposure

  3. Parent Education:

    • Mealtime strategies
    • Food presentation
    • Behavioral techniques
    • Progress tracking

  4. Follow-up:

    • Weekly monitoring
    • Diet expansion
    • Growth tracking
    • Team coordination

8. Cognitive-Communication Disorder

Description

Treatment session for an adult with cognitive-communication deficits following traumatic brain injury.

SOAP Note

Client Name: Michael Brooks

Date of Visit: 09/08/2024

Subjective

Michael Brooks, a 45-year-old male, presents for cognitive-communication therapy 4 months post-TBI. Reports ongoing difficulties with work tasks requiring multitasking and organization. Wife notes improvement in conversation tracking but continued challenges with complex information retention. Patient expresses frustration with memory lapses during important meetings.

Objective

  • Cognitive Assessment:
    • SCATBI Scores:
      • Attention: 80/100
      • Memory: 75/100
      • Organization: 70/100
      • Reasoning: 85/100
    • Functional Rating:
      • Task completion: 3/5
      • Memory strategies: 4/5
      • Problem-solving: 3/5
  • Communication Skills:
    • Topic maintenance good
    • Turn-taking appropriate
    • Processing speed variable
    • Abstract language limited
  • Executive Function:
    • Planning: Moderate difficulty
    • Organization: Needs support
    • Initiation: Independent
    • Self-monitoring: Variable

Assessment

  1. Cognitive-Communication Disorder
    • Attention deficits
    • Memory challenges
    • Executive function impact
  2. Functional Status
    • Work limitations
    • Strategy use improving
    • Support needs identified
  3. Treatment Progress
    • Good awareness
    • Strategy adoption
    • Generalization emerging

Plan

  1. Treatment:

    • Weekly sessions
    • Cognitive training
    • Strategy development
    • CPT Code: 92507

  2. Interventions:

    • Memory strategies
    • Organization tools
    • Attention training
    • Executive function tasks

  3. Support:

    • Work accommodations
    • Family education
    • Technology training
    • Resource provision

  4. Follow-up:

    • Progress monitoring
    • Goal adjustment
    • Outcome measures
    • Team coordination

9. AAC Evaluation

Description

Comprehensive evaluation for augmentative and alternative communication (AAC) needs for a child with cerebral palsy affecting speech production.

SOAP Note

Client Name: Sofia Rodriguez

Date of Visit: 09/09/2024

Subjective

Sofia Rodriguez, a 7-year-old female with cerebral palsy, presents for AAC evaluation. Parents report limited verbal communication, strong receptive language, and current use of basic picture communication board. Child shows interest in communication but frustration with current system limitations. Family seeking more sophisticated communication solution for academic and social participation.

Objective

  • Communication Assessment:
    • PPVT-5: SS 95 (37th percentile)
    • Expressive One-Word: Unable to complete
    • Communication Matrix:
      • Level 6-7 functioning
      • Intentional communication
      • Symbol use emerging
  • Motor Access:
    • Direct selection possible
    • Pointing accuracy: Good
    • Touch screen access: Fair
    • Switch scanning: Not needed
  • Current Communication:
    • Gestures: Consistent
    • Vocalizations: Limited
    • Picture use: Effective
    • Sign attempts: Few
  • Language Skills:
    • Comprehension: Age-appropriate
    • Symbol recognition: Good
    • Navigation: Learning
    • Message formation: Emerging

Assessment

  1. Complex Communication Needs
    • Severe dysarthria
    • Good language comprehension
    • Technology candidacy
  2. Access Capabilities
    • Direct selection viable
    • Motor planning adequate
    • Visual scanning good
  3. System Requirements
    • Dynamic display needed
    • Language expansion potential
    • Portability important

Plan

  1. Recommendations:

    • High-tech AAC device
    • Dynamic display system
    • Language software
    • CPT Code: 92597

  2. Implementation:

    • Device trial period
    • Customization needs
    • Training schedule
    • Support planning

  3. Training:

    • User instruction
    • Family training
    • School consultation
    • Team coordination

  4. Follow-up:

    • Implementation monitoring
    • Progress tracking
    • System adjustments
    • Outcome measurement

10. Adult Dysphagia

Description

Evaluation and treatment for dysphagia following recent stroke with focus on safe oral intake and swallowing strategies.

SOAP Note

Client Name: William Parker

Date of Visit: 09/10/2024

Subjective

William Parker, a 68-year-old male, presents for dysphagia management 2 weeks post-stroke. Reports coughing with thin liquids and difficulty managing solid foods. Family notes increased meal duration and anxiety about choking. Currently on mechanical soft diet with nectar-thick liquids. Motivated to return to regular diet consistency.

Objective

  • Clinical Swallow Exam:
    • Oral Phase:
      • Labial seal intact
      • Tongue range reduced
      • Oral transit delayed
      • Residue noted
    • Pharyngeal Phase:
      • Delayed trigger
      • Multiple swallows
      • Wet voice quality
      • Cough response present
  • MBSS Findings:
    • Penetration with thin liquids
    • Delayed pharyngeal response
    • Reduced laryngeal elevation
    • Residue in valleculae
  • Yale Swallow Protocol:
    • Failed thin liquid trial
    • Passed nectar-thick
    • FOIS Level: 4
    • EAT-10 Score: 18

Assessment

  1. Oropharyngeal Dysphagia
    • Moderate severity
    • Mixed mechanism
    • Safety concerns
  2. Current Status
    • Modified diet tolerance
    • Strategy use variable
    • Aspiration risk
  3. Rehabilitation Potential
    • Good motivation
    • Learning capacity
    • Support system

Plan

  1. Treatment:

    • 3x weekly sessions
    • Swallow therapy
    • Strategy training
    • CPT Code: 92526

  2. Interventions:

    • Exercises program
    • Compensatory strategies
    • Diet modifications
    • Safety precautions

  3. Education:

    • Patient training
    • Family instruction
    • Diet guidelines
    • Risk management

  4. Follow-up:

    • Weekly monitoring
    • Diet advancement
    • Strategy refinement
    • Team coordination

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