The "S" in a Teletherapy SOAP Note

Updated: Mar 25, 2021

It's likely every SLP has been reminded of the "if it wasn't documented, it didn't happen" philosophy when writing the subjective section of a SOAP note. When documenting a teletherapy speech session, the virtual environment has a few unique considerations that could impact The "S" in a Teletherapy SOAP Note.

Computer Notes

Pearson Clinical's telepractice implementation follows a "Five Theme Framework" (Eichstadt, Castilleja, Jakubowitz, & Wallace, 2013), which I've found helpful in organizing my thoughts for the "S" section in SOAP notes as well as teletherapy evaluation observations. While some of these questions may be similar to those that you mentally hash through in a in-person setting, there is definitely a tele-twist!


AUDIO/VISUAL Environment


  • Was troubleshooting required?

  • Was sound quality established and maintained, intermittent, delayed, or compromised?

  • Was video established and maintained, intermittent, delayed or compromised?

  • Were there background noises (i.e., pet, siblings) or visual distractions (i.e., objects on desk, snacks, toys, TV, video games)?


CLINICIAN Factors



STUDENT/CLIENT Factors


  • Did your student attend to the screen?

  • Did they actively interact on screen and participate in tasks?

  • Did your student just wake up in the morning or from a nap?

  • How familiar and comfortable with technology is your student?

  • How competent with technology is your student?


MATERIALS


  • What type of digital or non-digital task was most engaging?

  • How did your student respond - via microphone or chat box?


MISCELLANEOUS


  • Did you make any recommendations?

  • Did you discuss home environment implementation?

  • Were they early, on-time, late, or having "connection difficulties"?

  • Did they disconnect early or get "kicked out"?

SOAP Note Template

These questions can be helpful to ask while filling out your "S" section, but they certainly don't make report writing quicker. Are your SOAP notes taking WAYYY too much time? Are you looking for a clean, boring, black & white template that will get the documentation completed as efficiently as possible? Look no further...

  • Fillable Text Boxes

  • Drop down boxes for quick, frequently used verbiage

  • Customizable Drop down boxes (ability to freely type)

  • Automatic font re-sizing to fit your boxes

  • Auto-population of PHI and IEP goals in entire document

  • Digital signatures

All included in my Boring, Black and White SOAP Note Template for Teletherapy! This template is exactly what you've needed to reduce your documentation time.


RESOURCES

ASHA Telepractice

Pearson Clinical


-Angela C. Hancock, MSP, CCC-SLP


Spread the Word on Pinterest



227 views

Recent Posts

See All
Your thoughts are valued!
Rate This PostPoorFairGoodVery goodExcellentRate This Post

Thanks for sharing your thoughts! If you clicked the "send me info" button, check your email!