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Creating a Functional Therapy Plan: Therapy Goals & SOAP Note Documentation

Creating a Functional Therapy Plan: Therapy Goals & SOAP Note Documentation
Tatyana Elleseff, MA, CCC-SLP
January 14, 2015
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This text-based course is a transcript of the webinar, “Creating a Functional Therapy Plan: Therapy Goals & SOAP Note Documentation,” presented by Tatyana Elleseff, MA, CCC-SLP.

>> Tatyana Elleseff:  I am here to talk about one of my favorite topics: how we can create a functional therapy plan following the child’s assessment.  Some of our goals today are identifying the difference between goal and procedure, talking about the three phases of intervention planning, and the nature of goals and procedures for each phase.  We want to explain the four types of maintaining factors, list the differences between long-term goals, short-term goals, and session goals, and also to talk about how to write brief but functional SOAP notes. 

Goals vs. Procedures

Let's begin with making the distinction between a goal and a procedure.  Unfortunately, it is still an area that is a bit gray for a number of practicing clinicians and we want to make it as clear as possible regarding the difference.

Goals

Goals are formulated based on assessment findings.  They are the potential achievement by an individual, or in in pediatric cases, of a student or client with speech and language deficits.  We are hoping that by achieving those goals, they will improve their performance.  They are also the clients’ expected actions.  Our goals are directed and created in such a way to modify or compensate for factors that contribute to speech-language deficits.  We will talk at length about those factors.  They are called the maintaining factors, or the four areas of difficulty that could maintain or prolong the client’s experience in treatment. 

Procedures

Now that we have covered goals, which are what the client is expected to do and how they are expected to improve, we are going to talk about procedures.  Procedures are our plan of action.  They have nothing to do with the client in a sense of what the client is expected to do.  The client is expected to achieve goals.  We, clinicians, are expected to create procedures for that client, in order to assist the client with goal achievement.  When we are creating the procedures for the client to meet their goals, we are considering what to do with maintaining factors.  We think about whether we want to change them, eliminate them altogether, or compensate for them.  In cases of our very impaired clients who have multiple affected modalities, we want to compensate for those maintaining factors.  In our procedures, we want to create the best or optimum therapy interactions, context, and have the best actions during therapy sessions to further improve our clients’ functioning. 


tatyana elleseff

Tatyana Elleseff, MA, CCC-SLP

Tatyana Elleseff, MA, CCC-SLP is a bilingual speech-language pathologist who specializes in working with multicultural, internationally and domestically adopted as well as at-risk children with complex communication disorders in both hospital and private practice settings. She has presented for a number of medical, academic and non-profit organizations as well as speech language associations. She has been published in several journals and magazines including Advance for Speech Pathologists as well as ASHA Perspectives on School Based and Global Issues.



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