A Sensory Place — SOAP Note

Subjective

Client identity & presentation

Discipline Required

Client Name Required

Date of Birth Ch.35

Member Assist ID Ch.35

Date of Service Required

Time In Required

Time Out Required

Session Type

Provider Required

Location

Diagnosis / ICD-10 Required — select all that apply

CAS Speech Sound F80.0 Expressive Lang F80.1 Mixed Lang F80.2 Language Disorder F80.9 Social Comm F80.89 ASD F84.0 Dev Delay F88 Intellectual Disability F70 Sensory Processing Fine Motor Delay Gross Motor Delay Feeding Disorder Cerebral Palsy G80.9 Down Syndrome Q90.9

Caregiver Present Required

Caregiver Participation

Client Presentation

On time Cooperative Participated well Engaged Eager Attentive Required redirection Fatigued Wandering Movement breaks Full session

Caregiver / Subjective Report

Objective

Goals, data & performance

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Word / Task Probes Objective data

Assessment

Clinical interpretation & medical necessity

Progress Status Ch.35 Required

Progress Observations

Measurable progress Increased independence More self-initiation Improved with faded cues Requires max support Improved motor coordination Increased functional communication Increased task tolerance Improved sensory regulation Consistent with prior session Backing substitutions Fronting substitutions

Barriers to Achieving Outcomes Ch.35 Required

No barriers Motor planning Fatigue Behavioral factors Caregiver carryover Inconsistent attendance Sensory regulation Target complexity Medical factors

Skilled Service Justification Required — why qualified provider is necessary

Modified cue hierarchy Motor analysis Specialized technique Clinical response feedback Real-time task modification Error pattern remediation Sensory grading Adaptive equipment

Caregiver Education & Training DDD Required every session

Home program reviewed Cueing hierarchy Demonstrated understanding Targets reviewed Performance feedback given Home activities trained Sensory diet reviewed Adaptive strategies shown

Specific Service Activities Ch.35 Required

Additional Clinical Notes

Plan

Next steps & home program

Plan of Care Status Required

Next Session Focus

Home Program DDD Required every session

Daily practice Embed in routines Encourage communication AAC practice Sensory diet Fine motor practice Gross motor practice Encourage segmenting Visual supports

Home Program Frequency

Qualified Vendor Ch.35

Additional Plan Notes

✍

Signatures

Provider + Parent/Guardian — required every visit (DDD)

Provider Signature

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Parent / Guardian Signature Required every visit

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DDD Deadlines

Auto-calculated from your dates

Initial Eval Date

CPOC Signature Date

Auth End Date

Last Progress Report

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Generated SOAP Note

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Parent / Guardian Email

Admin Email (forwards completed note to owner)

Owner / Nash Email

Opens your device mail app pre-filled with the SOAP note. Workflow: therapist emails parent to sign, admin receives copy and forwards signed version to Nash. DocuSign integration available for automated e-signatures.

A Sensory Place · SOAP

Generated SOAP Note

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