Kent State University

Speech and Hearing Clinic

Progress Note

Client Initials: LC Page Number: 1

Date of Service: 9/7/17

Time/Duration of Service: 45 minutes

S (Subjective Statement/s):
(e.g. Briefly describe client’s state, mood/participation level for session, any newly reported
information and if home program assigned previously was completed)

LC was attentive and cooperative throughout the session. He was engaged with the clinician during
conversation and activities.

O (Objective):
Goals Results Comments Goal Revision?
List data for each skill Performance Conditions, If goal requires
area including trial Quality/Type/Amount of revision, check “yes”
information/percentages Cueing, Perceived and enter revised goal
Exertion in P section
1. Assess LC’s Met Not Met Only pronouns “he” and Yes
ability to # of sessions met: 1 “she” targeted, Moderate No
comprehend and support provided
accurately 5/5
produce
pronouns (he,
she, I, you)
during a
structured
activity.
2. Assess LC’s Met Not Met Accurately discriminated, Yes
ability to # of sessions met: 1 minimal support provided No
comprehend and
accurately 7/7
discriminate
emotions during
a structured
activity.

3. Probe for LC’s Met Not Met Moderate support provided, Yes
accurate use of # of sessions met: 0/1 additional data needed for use No
auxiliary verbs of auxiliary verbs within a
(are, is) and 5/6 present participles structured activity
present
participles
during a
structured
activity.
 Kent State University
Speech and Hearing Clinic
Progress Note

Client Initials: LC Page Number: 2

Date of Service: 9/7/17

4. Assess LC’s Met Not Met Minimal support provided Yes

ability to # of sessions met: 1 No
comprehend and
accurately 4/5
produce labels of
shapes during a
structured
activity.

5. Assess LC’s Met Not Met Maximal support provided Yes

ability to # of sessions met: 0/1 No
comprehend and
accurately 2/5
produce age
expected
prepositions.

6. Assess LC’s Met Not Met Minimal support provided Yes

ability to follow # of sessions met: 1 No
multi-step
directions.

7. Assess LC’s Met Not Met Independently took on roles Yes

ability to engage # of sessions met: 1 of character, reenacted No
in pretend play events, and used props
within a 5- demonstrated use of props, provided
minute play taking on roles, and
activity. concepts big/small and
hot/cold

Standardized Testing Completed: N/A

Speech and/or Language Sample Collected Yes No (If “Yes” Checked, State
Results/Analysis in Addendum)
Test/s Administered: Results:
 Kent State University
Speech and Hearing Clinic
Progress Note

Client Initials: LC Page Number: 3

Date of Service: 9/7/17
A (Assessment):
(e.g., Describe, analysis of client performance, cues required, changes in performance, safety,
fatigue, new problems identified, education provided, carryover with education provided, etc.)

LC was interactive with the clinician and was engaged during all of the activities presented
throughout the session. He demonstrated age appropriate pretend play skills, and was successful in
identifying shapes and following multi-step directions with minimal support. LC was able to
accurately comprehend and produce the pronouns “he” and “she” with moderate support through
the use of verbal cues. He was able to accurately discriminate emotions with labels when shown
visual cues, but demonstrated difficulties when asked questions relating to the meanings behind
those emotions. For example, he was able to choose which picture depicted the emotion “excited”,
but when asked the question, “What makes you excited?” he responded by selecting the picture
again. LC demonstrated difficulties comprehending and using age expected prepositions such as
“in, on, and under.” He required maximal support (direct models) in order to identify if an item was
“on” or “under” a line when looking at pictures. LC did not demonstrate any use of auxiliary verbs
(is, are) throughout a 50 utterance language sample, however this area was not directly targeted
within a structured activity. He demonstrated accurate used of present participles (e.g. running,
eating) during a structured activity with moderate support through the use of verbal cues. LC
benefitted from the use of stickers as a motivator to follow “speech rules,” as well as from the use
of gross motor activities throughout the session. A 50 utterance language sample indicated that LC
has a mean length utterance (MLU) of 3.48, which is appropriate for a child in Stage IV of Brown’s
Morphemes. The typical MLU for a child LC’s age is around 4.5. LC’s language sample did
demonstrated morpheme’s that occur in Stage IV, including articles and regular past tense. At age
4;10 LC’s MLU and produced morphemes indicate that he is in Brown’s Stage IV, which is typical
for a child 2;9 to 3;5 years of age.

P (Plan):
(e.g., Ongoing skilled need, new problems identified, home program area of focus; List current
goals)

Treatment will continue targeting prepositions, comprehension of emotions in oneself and others,
and sequencing and recall of events. Assessment will be continued for the use of auxiliary verbs, the
use of present participles, and the identification of pronouns in unstructured activities. Additionally,
a home program will be implemented targeting the area of identifying emotions in oneself.
 Kent State University
Speech and Hearing Clinic
Progress Note

Client Initials: LC Page Number: 4

Date of Service: 9/7/17
Updated Goals:
(e.g. List any updated/revised or new goals designated in O section)

1. LC will demonstrate comprehension (e.g. accurately identify and use pronouns of characters
within short stories) and use of age expected pronouns (he, she, I, you) in 90% of
opportunities provided during an open ended activity with minimal support.
a. LC will accurately comprehend and use pronouns (he, she) in 80% of opportunities
provided during and open ended activity with moderate support.
b. LC will accurately comprehend and use pronouns (he, she, I, you) in 80% of
opportunities provided during an open ended activity with moderate support.
2. LC will accurately comprehend emotions in oneself and others by predicting the resulting
emotion of a common event in 80% of opportunities provided within daily activities with
minimal support.
a. LC will accurately comprehend emotions in oneself and others in 70% of
opportunities provided within a structured activity with moderate support.
b. LC will accurately comprehend emotions in oneself and others in 75% of
opportunities provided within a structured activity with minimal support.
c. LC will accurately comprehend emotions in oneself and others in 80% of
opportunities provided within daily activities with moderate support.

3. LC will accurately sequence and recall past events in 70% of opportunities provided during
daily life with moderate support.
a. LC will accurately sequence and recall past events in 60% of opportunities provided
during a structured activity with moderate support.
b. LC will sequence and recall past events of a therapy session with 60% accuracy at
the end of a therapy session with moderate support.
c. LC will sequence and recall past events in 70% of opportunities provided during
daily life with maximal support.

4. This goal will be discontinued due to adequate skills already possessed.

5. LC will accurately comprehend (e.g. manipulate an object based on a given prepositions) and
use age expected prepositions (in, on, under, next to, behind) in 80% of opportunities provided
during an unstructured play activity with minimal support.
a. LC will accurately comprehend age expected prepositions (in, on, under, next to, behind)
by manipulating an object based on a given preposition in 70% of opportunities provided
during a structured activity with moderate support.
b. LC will accurately comprehend and use age expected prepositions (in, on, under, next to,
behind) in 80% of opportunities provided during a structured play activity with minimal
support.
c. LC will accurately comprehend and use age expected prepositions (in, on, under, next to,
behind) in 80% of opportunities provided during an unstructured play activity with moderate
support.
 Kent State University
Speech and Hearing Clinic
Progress Note

Client Initials: LC Page Number: 5

Date of Service: 9/7/17

6. The goal will be discontinued due to adequate skills already possessed.

7. This goal will be discontinued due to adequate skills already possessed.

Care Coordination:
Conference with: Parent/Caregiver Teacher Outside SLP Physician
Additional Discipline (list: ) Other
Date: 9/7/17 Items Discussed: The session began with a parent interview where the
clinician introduced the activities and goals of the session. The parent provided information of goals
that she would like targeted, including emotions and recall of events. After the session the parent
was brought back into the therapy room to discuss the client’s performance and the clinician’s
findings. It was noted that the client was cooperative and engaged throughout the session.
Response: In agreement.

________________________________ ___________________________________
Emily Cavanaugh Megan Malone, M.A. CCC-SLP
Graduate Student Clinician Clinical Instructor
 Kent State University
Speech and Hearing Clinic
Progress Note

Client Initials: LC Page Number: 6

Date of Service: 9/7/17

SOAP Note Addendum

(List/Explain any additional information including listing of additional
findings/analysis pertinent case)

LC’s language sample indicates a Mean Length Utterance of 3.48, and a Brown’s Morpheme stage
of IV, lower than that of a typically developing child his age. LC demonstrates weaknesses in
morphology, as seen by his lack of age expected prepositions, possessive –s, and independently
produced present participles and auxiliary verbs. He also demonstrates weaknesses in answering
complex questions, such as “What is something that could make you happy?” Syntactically, LC
demonstrates a lack of age expected infinitive phrases, conjunctions, and multiple embeddings
within sentences. LC demonstrated the accurate use of concepts such as “big, small, hot, and cold,”
and used descriptive language within spontaneous play. Receptively, LC successfully followed
multistep directions and answered simple yes/no and wh- questions. He demonstrated understanding
of vocabulary used within the session by accurately participating in all activities. Additionally, he
engaged in pretend play consistent with Stage IX of Westby’s Play Scale, which is typical for his
age range, by using dolls to act out play and using problem solving for events that occurred. He
engaged well with the clinician and interacted in a playful manner throughout the entire session, but
showed difficulties in recognizing emotions and their causes. LC demonstrated the sound errors of
substituting /w/ for /l/, /d/ for voiced “th”, and /w/ for /r/. All speech sound errors produced are
considered within the normal limits of articulation development for his age range.

Based on the initial findings of the clinician, it is recommended that therapy target expressive
language in the areas of morphology and syntax, as well as receptive language in the areas of
comprehending complex questions and sequencing events. Additionally, it is recommended that
therapy target pragmatic language with a focus in understanding the emotion’s of oneself, as well as
how to react to the emotion’s of others.
 Kent State University
Speech and Hearing Clinic
Progress Note

Client Initials: LC Page Number: 7

Date of Service: 9/7/17
C: Graduate Student Clinician
LC: Client

C: Should we hit another target?

1LC: Yeah
LC hits target
2LC: A blue one again!
C: Can you hit that red one up there for me?
3LC: Yes, I can
C: Oh so close!
4LC: I just wan it down!
C: Good Job, what does that one say? It wants to know what your favorite animal is!
5LC: Puppy dog!
C: Oh mine too!
6LC: Watch me.
C: Wow! Hey I want to show you something
7LC: What is it?
C: Look at this card I have, who’s name is that?
8LC: Wiam!
C: It says your name! And I have all these stickers. Do you want to wear a sticker on your shirt
or on the card?
9LC: Um, short.
C: To get stickers we have to have good speech manners. We have to be good listeners and
have safe hands and safe feet.
C: Is right here good?
10LC: Cool
C: Okay, let’s pick up my targets. What do you think is under that table?
11LC: Let see!
C: Oh my gosh, it’s bowling! Have you ever played bowling before?
12LC: Yeah have to hit dose!
C: You’re right! Let’s set up some bowling pins, how many should we set up?
13LC: one, two, free, four, five.
C: like that in a straight line?
14LC: Yeah, we gonna hit it!
C: Wow good job! So, before we bowl again we are going to talk about our feelings. What is
something that makes you feel happy?
15LC: Um to get a Jackson stone toy big one!
C: that makes you feel happy?
16LC: Yeah!
C: Oh I love that! I am going to show you some pictures, and we are going to talk about how
they are feeling. Look at these faces, can you show me which guy is happy?
17LC: Dat one
C: Good job!
 Kent State University
Speech and Hearing Clinic
Progress Note

Client Initials: LC Page Number: 8

Date of Service: 9/7/17
18LC: to get a Jackson stone toy
C: He’s happy to get a toy! How do you know he’s happy?
19LC: da Jackson stone toy!
C: Is he smiling?
20LC: Yeah! Cuz he wanna Jackson stone toy.
C: Can you make a happy face? Awesome!
C: Can you show me which guy is scared?
C: Good! How do you know he is scared?
21LC: So he can get a Jackson stone toy cuz a Jackson stone toy disappeared cuz he’s scared.
C: Ohh. Can you make a scared face? Good job!
22LC: I’m gonna knock um!
C: You’re going to knock the bowling pins down?
23LC: Yeah again!
C: Okay! Wow so close! Let’s try again!
C: Good job!
24LC: Got anotha one!
C: You’re such a good bowler! Let’s look at some more faces!
25LC: I’m gonna get it.
C: I’m going to hold this while we look at some more faces
C: Which one of these faces is mad?
26LC: Dat one!
C: How do you know he’s mad?
27LC: Grrrr!
C: Good Job! Which face is excited?
28LC: Dat one.
C: Good! what makes you feel excited?
29LC: um dat one.
C: Okay. Which one of these faces is sick? Good job! How do we look when were sick?
30LC: um cough!
C: Good job! We do cough when we are sick. Let’s take a turn bowling.
31LC: Dere is too many!
C: Oh no, I bet I can help you. Should I put them in a line?
32LC: Yeah, many of dem.
C: Okay let’s see it.
33LC: uh go dat way!
C: Okay is that better? You still got one! Can you get any more?
34LC: uh gaa! It roll!
C: It did roll you’re right!
35LC: Boing!
C: Oh you almost got it!
36LC: A yella one didn't knock over!
C: Okay try one more time! Good job, you were so good at this game! Thank you for playing
with me.
 Kent State University
Speech and Hearing Clinic
Progress Note

Client Initials: LC Page Number: 9

Date of Service: 9/7/17
C: Lets play a new game, but first. Were you a good listener?
37LC: yeah, anotha sticker!
C: Another sticker!
38LC: No a big one!
C: Oh you want a big one! Okay let’s play our next game!
39LC: Hi!
C: do you know your moms back there?
40LC: Hi I look at that!
C: Hey do you think you’re faster than me?
41LC: Yeah
C: Hmm I don't know!
42LC: Maybe I can beat you.
C: During this game you’re going to have to race me
43LC: Let’s do it!
C: Okay! So look, there are magnets on the back of the cards. You have to get all of the cards on
the chalkboard as fast as you can.
44LC: Yeah, as fast!
C: I’m going to race you there. But even though we are racing we have to make sure our bodies
are safe.
45LC: Yeah you right. Let’s do this!
C: Let’s do this. To get your card, you have to answer my questions.
C: Do you see this guy? Is he standing under the line, or on the line?
46LC: On the wine.
C: hmm try again. Which one?
47LC: uh swimming.
C: Look, he is under the line!
48LC: It reaches hundred!
C: lets race it to the board! Are you ready? Set, go!
C: Wow you are so fast! Can you tell me what this guy is doing?
49LC: um, super fast!
C: but what is he doing super fast?
50LC: um, can wun.

________________________________ ___________________________________
Emily Cavanaugh Megan Malone, M.A. CCC-SLP
Graduate Student Clinician Clinical Instructor