Speech therapy progress notes

Summary

• Use speech therapy progress notes to document client performance, track measurable outcomes, and guide future treatment decisions after each session.

• Follow a speech therapy daily notes template such as the SOAP format to organize subjective observations, objective data, assessment, and treatment plans.

• Record accurate performance data, including percentages and goal progress, so other providers can understand what occurred during the session.

• Create regular progress reports that summarize trends across multiple sessions and help communicate client achievements and ongoing needs to caregivers and other professionals.

When a speech-language pathologist (SLP) finishes a session, they record speech therapy progress notes. This enables the SLP to determine whether therapy plans need to be adjusted, helps to guide therapy from one session to the next, and provides justification for discharge. 

Speech therapy progress notes also facilitate communication between SLPs and other professionals working with the client as they are a tool of communication among the team. Furthermore, should an SLP be called to testify about a client years after services were provided, these written records will provide documentation.

What are speech therapy daily notes?

Daily notes summarize a therapy session. They can be recorded in multiple formats but often provide subjective reports from the client, observations made by the clinician, data gained during the session, as well as a plan for future sessions. 

While speech therapy daily notes often include tasks completed, they also record the client’s performance in measurable form. For example, if a client answered 9 out of 10 questions correctly, the daily note should mention that they achieved 90% accuracy for that goal during the session.

While taking daily speech therapy notes for every client may seem overwhelming, it is required by the American Speech-Language-Hearing Association (ASHA)—and even written into their Code of Ethics—because it is vital to a client’s success. ASHA advises that daily notes be recorded with enough detail for someone not present during the session to understand exactly what took place.

Once an SLP determines a good format or template for daily speech therapy notes, maintaining these records becomes effective and efficient.

Note that daily notes and progress notes refer to session-level documentation, which is distinct from progress reports, which summarize performance across multiple sessions.

Are daily notes the same as speech therapy progress notes?

Yes, speech therapy daily notes—or speech therapy progress notes—both refer to notes recorded after a therapy session. They provide a picture of how a session progressed and where the client is in terms of meeting their goals. There are various templates for daily speech therapy notes and progress notes; SOAP notes are a common one. 

The acronym SOAP stands for Subjective, Objective, Assessment, and Plan. Therefore, SOAP notes document a patient’s progress during a therapy session following the format of these four categories. SOAP notes are one way to organize speech therapy progress notes.

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What are SOAP notes for speech therapy? 

SOAP notes are structured and comprehensive daily notes that are written in summary format. The consistent structure of SOAP notes allows for easy comparison of progress across sessions. 

The following speech therapy daily notes template follows the SOAP note format:

Subjective

This is a brief statement of how the clinician thinks the session went. This information is not measurable, but more of an observation of progress. The client’s behavior and current state of cognition can be recorded in this section. Observations can be supported with comments from the client or caregiver. For example, “Alan reported that when tired, his word finding abilities worsen.” The subjective section should give a brief, clear picture of how the client participated during the session.

Example: Billy transitioned to the therapy room without difficulty. He was eager to work on his /r/ sound and noted that he practiced /r/ while reading books at home with his mother. The alligator game motivated Billy to work on his goals today.

Objective

This speech therapy progress notes section provides the measurable data gathered for each target goal during the session—this may include accuracy levels or percentages correct. In this section, the SLP notes where a client is in terms of meeting their goals. Terms such as goal met, goal not met, or progressing provide helpful information when planning the next session. Goals not addressed during the session should be noted. For example, “Open-ended questions goal not targeted today.”

Example: Billy is progressing toward meeting his goal. He produced the /r/ sound in the middle position of words with 90% accuracy with minimal cues provided. /s/ sound not targeted today.

Assessment

This is where the SLP assesses how the session went by interpreting the information in the first two sections. Ask yourself whether the client is making progress toward all goals. If the answer is no, what is holding the client back? Should therapy sessions be altered to allow for more progress? This is also the section to note the client’s response to therapy—were they happy with their progress or unmotivated today? Finally, the SLP can compare the client’s performance today to that of previous sessions. 

Example: Billy continues to improve his production of the /r/ sound in the middle position of words. He has maintained 90% accuracy for two consecutive sessions. 

Plan

In this final section of speech therapy progress notes, the SLP asks questions regarding future therapy sessions so a plan can be set. Is continued treatment necessary? If so, what activities will take place next session? Should the therapy schedule remain the same or can the frequency of sessions be reduced? It is also important to consider whether the client needs any further support or assessment from other professionals.

Example: Billy has achieved 90% accuracy for two consecutive sessions and requires one more session with 90% accuracy or higher before moving on to /r/ in another word position. Once Billy has achieved 90% accuracy or better for three consecutive sessions, /r/ in the final position of words should be targeted. Therapy materials will include picture cards of words with /r/ in the middle position and a motivational game.

Other templates for speech therapy progress notes:

Some SLPs prefer to follow the SOAP note template for daily speech therapy notes, separating each section to maintain detailed organization. 

Others prefer to record their speech therapy progress notes in one longer summary.

Example: Alice worked on categorizing nouns today. Given 20 pictures, she was able to accurately categorize animals and foods with 85% accuracy during a structured therapy session. Verbal cues were given as needed and helped her place the items in their respective categories. She worked eagerly with the reinforcement of taking a turn in a board game for every five pictures categorized. Alice will practice at home with picture cards provided. The next session will focus on categorizing independently without the need for cues.

For a more structured progress note that differs from the SOAP note format, the following daily speech therapy daily note template is another option: 

• Client information: Name, age, diagnosis, and therapy goals

• Baseline data: Initial assessment results for comparison and to measure progress

• Therapy activities: Specific interventions/activities used to target goals

• Progress data: Quantitative measurement of performance including percentage accuracy

• Observations: Qualitative observations of the client’s behavior, performance, and progress

• Homework: Suggested activities for the client to practice at home until the next session

• Recommendations for further sessions: Whether to continue therapy without changes or to make modifications to interventions or goals as needed

Speech therapy progress reports

While a speech therapy progress note refers to a detailed summary of one therapy session, a progress report refers to a more comprehensive overview of a client’s performance over multiple sessions. 

A progress report summarizes progress, highlighting changes over time, and may be shared with other providers or family members on the client’s team. If the speech therapy client is of school age, this report may be shared with the educational team and be part of a child’s Individualized Education Plan (IEP) and/or school progress report.

Sample progress report

Julie is a 6-year-old kindergarten student who has been attending speech therapy sessions twice a week for six months to work on the correct articulation of the /k/ and /g/ sounds. Initially, Julie was not stimulable for either sound and could not achieve correct production independently or with visual or verbal prompts. During therapy, Julie achieved correct production of both sounds in isolation after three therapy sessions and has made steady progress since. She has mastered the /k/ and /g/ sounds in all word positions when reading during structured therapy sessions. With continued therapy and practice at home, she will continue working towards the use of these sounds during unstructured conversation in the natural environment. Once Julie has achieved 90% accuracy for both sounds during structured conversation in the therapy room for two consecutive sessions, observation in her natural environment (e.g., home, school) will take place to ensure carryover of these skills.

Conclusion

Speech therapy progress notes require time and energy beyond therapy sessions. Once a clinician adopts the daily note template they prefer, notes can be recorded quickly and efficiently. Keeping organized records leads to better planning for future sessions, allows for progress reports to be written with ease, and enables clients to be more successful in meeting their goals.

Sources

• American Speech-Language-Hearing Association. (2024). Module three: Documentation of SLP services in different settings. 

• Cornett, B. S. (2006). Clinical documentation in speech-language pathology: essential information for successful practice. The ASHA Leader.

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