Stephanie Clouser SOAP Note

Client A

Adult Language

S: The client is an older gentleman who suffers severe verbal apraxia due to a CVA. He was very cooperative and participated in all therapy tasks, despite some obvious displays of struggle.

O: The client and clinician worked together on motor speech, auditory comprehension, reading comprehension, and graphic skills. Motor speech was assessed through the productions of a consonant + a vowel syllable, such as /b/ + /e/ and /b/ + /a/. The client produced these syllables with 90% accuracy with a dependency on facial tactile cueing. Auditory comprehension was assessed by following one and two step directions. The client completed one-step directions of point to the _____ with 100% accuracy on his own. The client also completed the two-step directions with 100% accuracy, but with moderate-severe cueing. Reading comprehension was assessed through reading a sentence and pointing to the appropriate answer. The client completed this task with 80% accuracy with moderate cueing. The clients graphic skills were assessed during a spelling task that used letter blocks. The client completed the task with 75% accuracy with moderate-severe cueing.

A: Overall, the client displays moderate-severe difficulty in correctly completing the tasks presented during the therapy session. Tactile, verbal, and visual cues were used alone and in combinations in completing many of the tasks. Although there are deficits in both areas, the client appears to be demonstrating more difficulties with his receptive language than his expressive language, as seen in his completion of the reading and auditory comprehension exercises.

P: The client is to continue practicing the tasks in each skill category (motor speech, auditory comprehension, reading comprehension, and graphics). Maintaining his attitudes of positivity and willingness to participate will prove beneficial in future encounters of these tasks.

LTG: 1. The client will be able to express his thoughts, ideas, and needs at phrase level with 80% accuracy. 2. The client will be able to apply receptive language skills at phrase level with minimal cueing with 80% accuracy.

STG: 1. The client will be able to perform motor speech tasks with 80% accuracy with minimal cueing. 2. The client will be able to demonstrate auditory comprehension through following one and two step directions with 80% accuracy with none-minimal cueing. 3. The client will appropriately comprehend reading tasks with 60% accuracy with none-minimal cueing. 4. The client will correctly perform graphic skills through spelling with block letters with 50% accuracy with minimal cueing.