Therapy

Student Responsibilities: Therapy

These are the responsibilities that must be fulfilled in order to receive an A in this clinic placement. You are responsible for knowing the information below and you are able to access this website at any time to refresh your memory. Please consult this page before asking me questions on this topic.
Treatment Plan (sometimes)
SOAP notes should be completed the day of the session.
PBIP should be maintained for clients using SPELL-Links
Summary Report (sometimes)
Because I am supervising multiple students/clients at the same time, I may need you to provide lesson plans so that I can know exactly what is happening with each client. Lesson plans can be simple. It is better to overplan than underplan.
Arrive 15-30 minutes prior to the session to allow time to review lesson plan, gather materials, and ask questions.
YOU ARE EXPECTED TO BE PREPARED to conduct the session. DO NOT show up with no plan and/or no materials. If you are not sure what you should be doing, reach out to me well before the session and I will help you.
Data needs to be collected for each session. I often collect data in terms of how much support the child requires to be successful at a given task (e.g. maximal/moderate/minimal assistance). In some circumstances it will be appropriate to collect data in terms of percent correct or other quantitative measures.
Just like with a real job, if you are sick or cannot come to your session for another reason, you are expected to find a substitute and give them a lesson plan.
Please refer to Clinical Competencies for SLP Students to be CF Ready to review expectations based on your semesters of experience.

SOAP Notes

SOAP notes should be completed the day of the session and forwarded to me.
Be sure to completely fill in the information at the top of the SOAP note.
Unless we are doing testing during the session, Tx sessions are CPT 92507.
Be aware that families can view SOAP notes.
Use the child's name. Do not say "client"
Do not use flowery, overly-complicated words or sentences. Go for clinical, objective language.
Do not call a child defiant, difficult, or resistant (or any other negative judgement).
You can say that a child had difficulty self-regulating, or that a child had difficulty attending to the tasks that were presented to him/her, or that a child required maximal prompting or redirection to stay on task. You can also quote things a child says, e.g. "Jane stated that she did not want to finish the activity because it made her head hurt".
Try not to refer to yourself at all. Instead of saying "the clinician presented a visual timer", say "Johnny was given a visual timer".
S: This is where you state subjective, non-data information. For example, if the child arrived on time, if they were having trouble self-regulating, if they demonstrated difficulty attending, strategies you used that were helpful, games or activities they enjoyed. DO NOT INCLUDE DATA HERE.
O: This is where data goes. ONLY HERE. The goals should be written here in bold followed by the percentage for that session. If the goal is met, write GOAL MET after the percentage. If the activity was not completed, write IN PROGRESS after the goal. NOTHING EXCEPT GOALS and DATA go here. Include the SPELL Links lesson # and Activity # with each goal if your client is using SPELL-Links
A: This is where you draw conclusions based on the information in S and O. An example would be that the child "demonstrated mastery of (insert goal here)." or "demonstrated improvement/continued difficulty with (insert goal here)" or "increased accuracy when X strategy was used".
P: This is where you state the exact lesson plan for the next session. DO NOT BE VAGUE HERE. Say, "Move on to PA warmup N2, Spell Links Lesson 7, Activity 1". State any strategies you plan to use the next time. (e.g. "Continue to use visual timer", etc.). If you get sick, a substitute should be able to find your last SOAP note and know EXACTLY what they need to do.
At the bottom of the SOAP note, put an X by the box that says the client did not need an interpreter and by the box that says the person with the client did not need an interpreter.

Typhon

For in person clients, the clinical site at the top is MHSC and the setting type is home site (university clinic)
For virtual clients, the clinical site is MHSC and setting type is distance telehealth.
Be sure to put the number of minutes by the type of therapy.
It doesn't matter what kind of insurance the client has.
Link your entries (that way I can check the first one and I will know that the linked entries are also correct).
I will check your first round of Typhon entries and will approve them monthly after that.

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