Get Answer: Intervention Soap Note Question Guide

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Original Question

Intervention: SOAP Note: Jack Rationale The purpose of this assignment is to write a SOAP note from Jack’s session. (Write 3 different SOAP notes according to the Simucase information down below) Directions After completing Jack’s Intervention session in Simucase, complete a SOAP note from his session. Due Date: Check course syllabus SOAP NOTE EXAMPLES: Subjective: “XX’s parents reported that his grandparents came to visit this past weekend and they could understand his speech a lot better than the last time they visited 3 months ago.” Objective: The client produced final consonants in modeled words with (34/40) 85% accuracy Assessment: “XX benefits from visual and tactile cues in addition to a clinician model to accurately produce /t/. Accuracy has increased by 20% since the last session.” Plan: Continue to target final consonants in words but fade the model and move to unmodeled words when producing 3-4 syllable words Please consult the grading rubric when completing your SOAP note: Subjective: 20 Points Clear and concise impressions such as affect, comments made by client, changes in medications, therapies, physicians, etc. (10-20 points) Appropriate use of quotations when needed (10 points if applicable) Objective: 20 points Accurate data from goals and level of cuing used. Measurable information only (10 points) Data is relevant to therapy goals and diagnosis (10 points) Assessment: 20 points Interpretation and analysis of subjective and/or objective data with clinical reasoning/rationale (10 points) States progress toward goals (5 points) Provides a clear summary statement reflecting patient status/performance in the therapy session (5 points) Plan: 20 points Describe what will be done in the next session(s), i.e., any modifications to cuing, goals, additional testing needs, etc.(15 points) Plan aligns logically with the Assessment section (5 points) Professionalism and Writing Mechanics: 20 points Uses professional language, including appropriate medical/clinical terminology (5 points) Free from grammatical, spelling, punctuation errors, consistent verb tense (10 points) Follows correct SOAP format (5 points) ——————————————————————————————— Jack- Intervention (SLP) Simucase Information Learning Mode: Recommended time for completion is 90 minutes. Jack is a 16-year-old junior in high school with a fluency disorder diagnosis. You are the speech-language pathology practitioner assigned to provide intervention to Jack. Baseline Data: Speech Samples: Jack Describes his speech- stuttering is repetitions and a couple of blocks here and there. Speech Sample- How to play tennis and Tennis Coach Story Client Interview Concerns: what’s going to happen to him in the workplace Tell me about your difficulties with stuttering. “Being ridiculed about it; feels discriminated and he tells them about it (Tells a story about one of his friends mocking him and how his friend apologized), being cut off in conversations, people judging you” Are there times when your stuttering gets worse? In groups; presentations; talking to girls; anything out of the house Tell me about some of the exercises you have used. Continuous phonation, cancelation, reduced tension, and easy onset Are there tools that help you when you stutter? Use cancellation easy onset and continuous phonation and reducing tension lessons stutter blocks Session Objectives When reading texts, Jack will utilize strategy for inserting scheduled pauses while reading aloud with 80% accuracy. When engaged in academic tasks, Jack will identify, plan, and utilize learned fluency strategies in a hierarchy of situations from easy to difficult. When given assistance from the SLP to identify appropriate content, Jack will develop and present a brochure about stuttering to classmates and teachers to help him feel comfortable and confident in talking about stuttering. Collaborators: You contact the High School Literature Teacher High School Literature Teacher:Hello, Jack is in my literature class. He is a very pleasant young man who’s very motivated to do well. How can I help you? Describe your classroom setting. High School Literature Teacher:I generally encourage class discussion and serve as a facilitator rather than a lecturer. We read many books throughout the year, so participation is expected. I grade participation and effort within our classroom discussions. Students receive a grade for writing assignments as well. How is Jack doing in your class? High School Literature Teacher:Jack seems to be keeping up with the reading assignments. His homework is always on time; however, he rarely participates in the group discussions. When he does participate, he often has a difficult time getting his point across due to the stuttering. He seems to stutter the most when he feels pressured or is trying to win an argument. How did Jack do with the monologue assignment? High School Literature Teacher:The students have been giving oral monologues and are expected to memorize and present the monologue in front of the class. Jack is scheduled to present next week. I know he’s been practicing and devoting a lot of time to preparing. Is Jack bullied or teased? High School Literature Teacher:I am not aware of any teasing at this time. I have a zero tolerance for bullying. You contact the Mother Mother:Hi, I’m Jack’s mom. Do you have any questions for me? What are your concerns for Jack? Mother:Jack has struggled with stuttering his whole life. As a teenager, the stress of stuttering has really affected his social life. He feels anxious and isolated from his friends. Describe Jack’s speech. Mother:Jack has the most difficulty when he gets nervous or angry. He repeats sounds and words and also gets stuck at times. Jack also gets frustrated with his stuttering, especially when he is teased by others or when he is cut off in the middle of a sentence. When did the speech problem begin? Mother:He began stuttering around two or three years old. How do you help Jack at home? Mother:I do not interrupt him and I give him time to speak. Is there a family history of stuttering? Mother:There is a family history of stuttering. Jack’s dad, who’s a physician, and his grandfather both stutter. However, Jack’s sisters have no learning or fluency issues. You contact the Supervising Speech-Language Pathologist Supervising Speech-Language Pathologist:Hello, I am your supervising speech-language pathologist. Do you have any questions for me before you get started? What do you do to motivate Jack in your sessions? Supervising Speech-Language Pathologist:Jack is internally motivated. He works hard at every task you give him. What is Jack’s knowledge of stuttering? Supervising Speech-Language Pathologist:Jack is very active in educating others about the typical difficulties faced by many children who stutter. He has been active with the anti-bullying initiative at his school. Jack enjoys researching this topic and making others aware of his own personal struggles. What types of activities do you do with Jack? Supervising Speech-Language Pathologist:Jack has been working on creating a brochure explaining what stuttering is. He has also been practicing using easy onset when reading out loud. What is Jack’s diagnosis? Supervising Speech-Language Pathologist:Jack has a mild to moderate fluency disorder characterized by repetitions at the sound, syllable, and word level. Additionally, he has blocks of one to three second duration. He has difficulty monitoring rate and vocal intensity, especially in social situations. Jack also has a seizure disorder. What progress has he made? Supervising Speech-Language Pathologist:Jack continues to make progress with using his techniques to manage stuttering in various situations. He is also making progress to advance to more difficult speaking situations. Which goals should I target during this session? Supervising Speech-Language Pathologist:Jack has goals for increasing his ability to speak fluently by using techniques to manage stuttering at home, school, and social settings. Additional goals are for reducing negative reactions to stuttering that lead to struggle, modifying stuttering by replacing it with less tense disfluencies, helping Jack feel comfortable talking about stuttering, reducing avoidance behaviors, and increasing confidence in social communication settings. You can find more information in his IEP. Please work with Jack on reducing his rate of speech when reading aloud, preparing for his upcoming monologue presentation in his literature class, and finalizing the stuttering brochure he has been working on. Treatment 1.Book: Modify Speaking Rate and Reduce Tension Reading Task Description: Jack is prompted to use easy onset, continuous phonation and add pauses to control his rate of speech while reading text aloud. 2.Completing and Presenting Stuttering Brochure Description: Jack completes his brochure and prepares to present his “What Is Stuttering?” brochure to classmates in the lunchroom.: Got mixed reactions; made a brochure about how stuttering affects him and suggestions to people who encounter a stutterer; he states most of his peers didn’t know that what they were doing was wrong 3. Modify Speaking Rate and Reduce Tension Monologue Task Description: Jack practices reciting Shakespeare monologue using easy onset, continuous phonation and adding pauses to control his rate of speech. Unsure about this: Number of disfluencies: and Enter the frequency of disfluencies. (The number of disfluencies divided by the number of words) Skills Check: Jack presented with disfluencies of Prolongations, Repetitions revisions and blocks Client Progress: Goal Met: Insert scheduled pauses while reading aloud with 80% accuracy. 5. Goal Not Met: Utilize learned fluency strategies in a hierarchy of situations. 6. Goal Met: Develop and present a brochure about stuttering to classmates and teachers. Take home activity: -Add Pauses to Monologue Text -Practice Presenting Monologue to Audience at Home -Present Stuttering Brochure to Extended Family Members Summary: Jack cooperated throughout the session and met two of his goals. He completed and presented his stuttering brochure and inserted scheduled pauses while reading aloud. He did not utilize fluency strategies appropriately during the monologue activity. Provided take-home activities and reported session results to supervising SLP. Continue plan of care.

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