Speech Therapy Soap Note
Prepared By: [Your Name]
I. Subjective (S)
A. Patient Report
The patient reports continued difficulty with word retrieval and mild frustration during conversation. They mention that they have noticed slight improvements in their speech clarity over the past week but still struggle with complex sentence construction.
B. Concerns
The patient expresses concern about the inability to recall certain words during conversations at work and feels that this affects their confidence in social settings.
II. Objective (O)
A. Observations
The patient was able to complete a series of speech exercises focusing on articulation and word retrieval with moderate accuracy. Speech rate was slightly slower than normal, with occasional hesitations during conversation.
B. Data Collected
Articulation: 85% accuracy in targeted sounds.
Word Retrieval: 70% accuracy in spontaneous speech tasks.
Sentence Structure: Mild difficulty in constructing sentences with appropriate grammar and complexity.
III. Assessment (A)
The patient has made slight progress in articulation but continues to experience moderate difficulty with word retrieval and sentence construction. Progress is slower than expected, possibly due to anxiety during communication, which may be impacting overall performance. The current treatment plan is partially effective, but more focus on anxiety-reducing strategies could be beneficial.
IV. Plan (P)
Continue with articulation exercises and word retrieval tasks in therapy sessions.
Introduce cognitive strategies to reduce anxiety during speaking situations.
Increase focus on sentence construction with both structured and unstructured tasks.
Review progress in two weeks and adjust treatment goals if necessary.
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