Prepared by: Gayla S. Green from Vibrant Vision Studios
Date: 23rd October, 2050
This SOAP Note focuses on the Speech Therapy sessions of Lily Thompson, a 37 year-old female, to properly track her progress, set therapy goals and outline further actions. The SOAP template is broken down into four key sections: Subjective, Objective, Assessment, and Plan. Each section provides crucial information regarding the patient's current condition and future therapy directions.
Subjective
Patient's report of difficulty in speaking clearly
Frequent slurring and stuttering during speech
Reports feeling frustration stemming from speech difficulty
Objective
Height: 5'7", Weight: 145 lbs, 37 years old
Evidence of articulation errors observed during speech
Difficulties in speech fluency
Assessment
Lily Thompson is experiencing difficulties with speech fluency and clarity, observed as slurring and stuttering. These issues could be causing her significant distress and frustration. Further assessment and a personalized speech therapy plan is required for improvement.
Plan
Recommendation of regular speech therapy sessions
Structured exercises focusing on pronunciation and articulation
Empowering patient with coping strategies and techniques to manage frustration
