The SLP and SOAP Notes

In private practice, treatment notes are an important part of what we do.  It allows us to chart the progress of our students, keep on track with treatment, plan for future sessions and re-evaluate our methods each time we work with a student.
438_3370877Traditionally these notes are done by hand, but the new wave is to keep track electronically.  In order to record notes, first and foremost, you must have privacy controls in place.  This means using a password on your ipad or computer so others cannot login accidentally or on purpose to view client notes.
80_2640019Second, you need a backup system so that if notes are deleted accidentally, you are able to retrieve them easily.  Using a cloud based storage system such as iCloud allows you to access the notes across devices.  However, if you delete a file on your iPad, it will be deleted on your iCloud, so think about using another cloud-based storage system like Dropbox to avoid accidental deletions.
A final level of security for those using digital devices is to backup your computer with an external hard drive, also password protected, and stored at another location outside of your office.
112_2934062I use my iPad to record notes on Pages during sessions.  The iPad takes up less space on the table than a paper folder would.  It allows me to quickly record notes as we go and takes less time away from the student while we are working.  The best part about typing notes and printing them out every few months is that it saves paper.  Typing my notes stores about 1.5 months worth of notes on one side of a printed page.  When handwriting my notes, I could only fit about 2-3 weeks worth per side of a page.
573_3180490Finally, the newest trend is to create a Google form, spreadsheet or document to record progress for students.  Graphs and tables can enhance the visual factor of a student’s progress.
What’s your preferred way to take notes during your speech-language sessions in your private practice?