SLP Documentation Guide: Cognitive-Communication
SOAP Notes
Even though SOAP notes are redundant, I like to stick with the formula for all of my daily billing/treatment notes because it helps payers/auditors know what skilled services are provided with daily objective performance. Ultimately it shows that we actively working towards the LTGS/STGs each session. I have found that the “build” feature on Casamba or NetHealth is limiting and lacks how each session is personalized for each patients’ unique needs.
During my CF year, documenting skilled cognitive-lingustic treatments were the most challenging for me because cognition is SO complex. I can proudly say I think I’ve mastered a formula— I’ve been audited 3+ and, each time, was complimented on how thorough yet succinent my notes were.
Subjective: relevant, subjective information about the session (e.g., who was present during session, any notable comments).
Pt A&Ox3
Pt demonstrated increased lethargy this session characterized by >3 second response delay
Pt seen in SLP office with caregiver present
Pt presented with difficulty sustaining attention to structured tasks
Pt reported brain fog today d/t lack of sleep. Nsg staff notified and aware.
Objective: objective data/performance, specific treatment tasks completed with levels of cueing required/provided. What did they do independently?
“In order to delay recall, pt recalled 5 novel words s/p 10-minute delay x 80% accuracy, given min. cues.”
“Pt benefits from min. verbal cues to use verbal rehersals, association, and visualization as internal compensatory memory strategies.”
“Performance decreased to 60% when SLP increased complexity to recall 5-words s/p 15-minutes.”
“Pt (I)ly recalled 4-words s/p 5-minute delay x 100% accuracy. Min. contextual cues required when SLP increased complexity to delay recall 5 words s/p 10-minute delay.”
Assessment: What is the patient’s current level?
“Pt continues to present with mild-moderate cognitive- linguistic impairment, specifically affecting the domain of delay recall, short-term memory, and sustained attention.”
“Functional gain in use of external and internal compensatory memory strategies (e.g., calendar) have allowed for increased social/functional communication, decreased agitation/confusion, and the ability to complete functional daily living tasks with fewer cues. Pt benefits from min. verbal cues and supplemental time for cognitive tasks”
“The pt still has deficits in attention, short-term recall, working memory which limit the pt’s functional and social communication, ability to execute ADLs without assistance, and overall quality of life.”
“Pt has yet to receive therapeutic potential and will continue to benefit from skilled ST services.”
“Overall, patient's functional performance is improving as a result of instruction in compensations, modifications and adaptations”
Plan: Any modifications or changes to treatment plan are indicated here
“Goals remain appropriate, cont. POC”
“Cueing hierarchy was modified to limit tactile/verbal cues to enable greater independence in patient's use of compensatory memory strategies”
“Modified POC will include caregiver training re: communication partner strategies prior to d/c”
I hope this inspires you to write objective and accurate notes. Our documentation provides more than reimbursement— it is a piece of our clinical knowledge and facilitates communication to other SLPs and health care providers necessary for patient recovery.
