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Speech Therapy SOAP Notes Made Easy

20 September 2022

September 20, 2022

In: Therapy Documentation Resources

speech therapy session


  • Manually documenting speech therapy SOAP notes can take valuable time away from patients and lead to organization and compliance issues.
  • The right therapy EMR streamlines your SOAP notes process and simplifies documentation for speech and language therapists.
  • Cloud-based therapy EMR like ClinicSource use customizable templates and automated features to minimize time spent on documentation and maximize patient care.

Manually documenting speech therapy SOAP notes is time consuming and can lead to organizational and compliance issues for your practice. A completely integrated therapy EMR simplifies therapy documentation with pre-formatted, customizable templates and automated features. 

The right therapy practice management software helps you quickly and accurately complete documentation to maximize your time with your clients. 

Documentation Challenges for Speech Therapy SOAP Notes

For speech and language therapists (SLPs), one-on-one time with clients is crucial. Various treatment approaches, such as oral-motor therapy, articulation therapy, or language intervention activities, require you to interact with your patients to ensure they progress. 

According to the American Speech-Language-Hearing Association (ASHA), documentation must match the setting where you provide care. You must write SOAP notes in goal-oriented terms, demonstrate progress with the client, and remain compliant with insurance and CMS reporting requirements. Adhering to these detailed requirements takes time, and it’s easy to miss one or two important elements, which can result in issues with insurance claims, billing, or compliance. 

Without the right therapy EMR, accurate documentation can feel burdensome and reduce the time you have to spend with your clients. 

smiling speech therapist

How ClinicSource Simplifies Speech Therapy SOAP Notes

ClinicSource is an all-in-one speech therapy EMR and practice management system that works to simplify documentation for SLPs, including SOAP notes, treatment logs, and care plans. With ClinicSource, you have access to customizable templates that streamline documentation, so you don’t have to spend hours each week on administrative tasks. 

The following ClinicSource features make speech therapy SOAP notes easy for SLPs. 

Drop-Down SOAP Notes Templates

ClinicSource provides you with SOAP notes templates designed specifically for SLPs. These templates automatically populate goals from your care plan and goal assistance level and achievement percentage options. These features make it easy for you to record your client’s daily or weekly progress. 

Our SOAP note templates allow you to record therapy-specific notes that sync with other software components effortlessly. You can quickly record and view functional outcomes for therapies you use with patients, including prompt or diet levels. 

ClincSource’s complete integration also means entering speech therapy diagnostic billing codes in your SOAP notes with a simple drop-down menu. This eliminates having to search through DSM-V and ICD-10 codes and simplifies your billing process. 

Customized Reporting Templates

To further streamline documentation, ClinicSource offers customizable reporting templates that you can use for adult and pediatric patients. Our software organizes these templates by therapy disciplines, so when you choose Speech Therapy (ST), all reporting is relevant to your practice. 

With ClinicSource, you can easily report patient progress, treatment approaches, and diagnosis codes, keeping you compliant and audit-ready if needed. 

Intuitive and User-Friendly Platform

ClinicSource features an intuitive, user-friendly interface, making it simple for you to learn and implement for your practice. Our interface was designed by a speech and language pathologist, offering you internal search and retrieval features so you can find all the information you need for accurate reporting and documentation. 

The platform’s design, including drop-down menus and pre-formatted templates, automatically focuses on the modality you choose, giving you codes and diagnoses relevant to your discipline. If needed, you can customize your platform and add services as your platform or treatment modalities change. 

Pre-Programmed Treatment Log

ClinicSource uses a therapist-designed treatment log that streamlines session recording. You have access to pre-programmed CPT, diagnosis, and G-codes so you can easily select the options that fit with the treatment you use for your patients during your sessions. When you combine this feature with our library of SOAP notes templates, reporting and documentation are easier than ever. 

Tailored Care Plan Templates

ClinicSource’s care plan templates allow you to choose from procedures and goals specific to speech and language pathology. We offer an extensive Goal Library with hundreds of relevant objectives pre-populated for easy inclusion in your care plan. Once you select your goals, they automatically flow throughout your client’s notes, eliminating the need to retype information. 

Along with care plans, you can administer standardized assessments such as the CAAP-2, OWLS-II, and GFTA-3. You can also input raw or standardized scores, age equivalences, percentile ranks, and other elements into your care plans and SOAP notes with the touch of a few buttons. 

ClinicSource’s reporting capabilities let you populate and print these care plans and results for third parties like consulting physicians, parents, and insurance companies.

Compliant Documentation

ClinicSource ensures that your patients’ PHI stays secure and complies with Health Insurance Portability and Accountability Act (HIPAA) regulations. It updates automatically with any changes in HIPPA guidelines to keep your practice up to date at no additional cost to you.  

The HIPAA Security Rule requires all electronic PHI to be backed up in a secure location with controllable access during a disaster. Our software keeps your patient data safe with automatic encryption and backup, with multiple data centers in cases of data loss. Rather than creating a password-protected document to send to a healthcare provider, ClinicSource allows you to securely email patient records to a patient’s healthcare provider.

typing on a laptop

Streamline Your Speech Therapy SOAP Notes With ClinicSource

ClinicSource provides an all-in-one therapy practice management software for therapists to keep their notes up to date, easily accessible, and in compliance with HIPAA. Thanks to its intuitive user interface for speech therapists and staff, our software offers a set of reporting templates and treatment logs to make SOAP notes fast and easy. 

Simplify your documentation and improve productivity, regardless of the size of your practice. ClinicSource will help you focus on your patients and improve the care you provide every day. 

Book a demo today to learn how ClinicSource can streamline speech therapy SOAP notes, reporting, and documentation for your practice.

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