��AAMU CSD Clinical Procedures
CSD 516/321/406--Observation: Academic Clinic
Esther Phillips-Embden MA, CCC/SLP/L
Dalaina Horton, MS, CCC/SLP
Alabama A&M CSD Clinic Manual: Policies and Procedures 2026
Important Considerations:
Alabama A&M CSD Clinic Manual: Policies and Procedures 2026
Important Consideration:
II. How are clinical reports different from composition writing?
Behavioral Objectives (BO)�Defined
A behavioral objective is a statement that describes a specific target behavior in observable and measurable terms
Behavioral Objectives (BO) Components
Behavioral Objectives (BO) Components (cont.)
Behavioral Objectives (BO) Components (cont.)
1. The “Do Statement”/performance statement
Behavioral Objectives (BO) Components (Performance cont.)
i.e. the client will be able to demonstrate knowledge of five body parts (by labeling/naming them after clinician model) with 90% accuracy.
Behavioral Objectives (BO) Components (Performance cont.)
The client will correctly label/name five body parts, following clinician’s model with 90% accuracy
Behavioral Objectives (BO)�Components (Performance con’t)
Behavioral Objectives (BO) Components (cont.)
2. The Condition Statement
Identifies—
Behavioral Objectives (BO) Components (Condition cont.)
Example of Condition statement used:
The client will correctly label/name five body parts, following clinician’s model with 90% accuracy
Behavioral Objectives (BO) Components (cont.)
3. The Criterion Statement
Measures-
Behavioral Objectives (BO) Components (cont.)
3. The Criterion Statement
Measures-
In speech pathology the criterion statement is frequently stated in terms of accuracy
(ex. percent correct, within a given time period, minimum #of correct responses out of # of trials)
Behavioral Objectives (BO) Components (Criterion cont.)
Examples of Criterion statements:
The client will correctly produce target…
i. In 90% of his attempts
ii. In 90% of all appropriate contexts
iii. 8 out of 10 attempts
iv. 8 out of 10 trials
v. For 20 of 25 pictures
vi. With fewer than .5 stuttered words per minute
vii. 3 conversational turns.
Examples of Well-Written BOS��The client…
will correctly produce the /r/ phoneme in all positions of words in 90% of his attempts.
2. will correctly imitate /s/ in isolation in 8 of 10 attempts.
3. raise his tongue tip to the alveolar ridge with his mouth open at least 1 ½ inches on 8 or 10 trials.
4. auditorily discriminate (by raising his hand) /s/ from /f/ in consonant-vowel combination in 90% of his attempts.
5. Correctly monitor (state if correct or not) production of the /l/ phoneme during spontaneous conversation in 90% of his attempts
6. correctly monitor (self-correct) 90% of the incorrect /s/ productions during reading.
Application and Importance of Behavioral Objectives
The application of being able to write and understand BOs is crucial in speech pathology
Behavioral objectives are seen the 5 main reports used for client care in AAMU CSD Clinic:
Dx Report, ITP, LP, SOAP, Semester Summary Reports
❖ Vary in length
❖ Written after each therapy session and/or weekly (AAMU CSD Clinic)
❖ Has important functions:
1. Enable the clinician to monitor the tx program on a continual basis and implement any necessary changes immediately
2. Provide info on a daily/weekly basis to other professionals who also may be working with the client (OT, Social worker, PT, MD, etc)
3. Facilitate the continuity of tx by allowing another clinician to provide services in the event of unexpected clinician absence
IV: Progress Notes �(SOAP notes)—Anatomy
SOAP Notes are divided into components
S: Subjective Data
O: Objective Data
A: Assessment
P: Plan
IV: Progress Notes �(SOAP notes): Anatomy
S: SUBJECTIVE DATA
Reports clinician’s observations regarding relevant client behavior that will directly affect therapy progression--
❖ Temperament
❖ Physical condition
❖ Motivation
❖ Behavior
❖ Symptoms and complaints
“Client seemed sleepy and stated that he was stressed from a long day at school. Client c/o shoulder pain”
Also includes Information re: client or family’s attitude;
IV: Progress Notes �(SOAP notes): Anatomy
O: OBJECTIVE DATA
Reports…
❖ Data that can be measured
❖ Client’s performance toward all stated STGs as documented on the lesson plan in measurable, objective and skilled terminology
❖ Test findings
Example: ”The client was presented with a worksheet to change nouns and verbs from singular tense to plural tense. The client achieved 100% accuracy independently. This is a 33% increase in comparison to the previous session.”
NOTE: There will be times when all STGs will not be addressed in a given session due to time constraints. If a goal from the lesson plan was not targeted, state the reason.
IV: Progress Notes �(SOAP notes): Anatomy
A: ASSESMENT
Reports the clinician’s interpretation of the client’s condition or level of progress
Interpretation includes:
❖ Clinician’s analysis regarding client’s performance on previous therapy sessions
❖ Indicates client’s progression or regression on stated goals
❖ Professional opinion made by the clinician about the effectiveness and appropriateness of the tx plan
❖ Justification statements for continuing tx
❖ Meaning of test scores
Example: “The client demonstrated an improvement on all tasks attempted. She did however, show the most improvement on the subject-verb agreement task which she has had some difficulty with during the last two session.”
IV: Progress Notes �(SOAP notes): Anatomy
P: PLAN
Reports specific measures designed to manage the client’s problem.
Includes:
❖ Recommendations to continue therapy or assessment
❖ Justification for current therapy needs based on the information documented in the “O” and “A” sections of the SOAP note
❖ Proposed therapy targets for the next session
❖ Details of modifications to the treatment plan
Example: “This clinician will continue with LTGs and STGs as stated on the ITP.”
IV: Progress Notes �(SOAP notes): Weekly, 1x/wk
DATES | PROGRESS NOTES | INITIALS |
09/17/25 | S: The client was accompanied to the diagnostic session by his mother. The client willingly participated in both assessments. The clinician and the client’s mother briefly discussed the client’s results thus far and the test that will be administered in the upcoming diagnostic session. | TT |
09/17/25 | O: Articulation: The clinician administered the Goldman-Fristoe Test of Articulation-2 (GFTA-2). The clinician administered the sounds-in-words subtest and the sounds-in-sentences subtest to determine any incorrect productions of consonantal phonemes in the initial, medial, and final positions. The results are as follows: Sounds-In-Words Score Summary *Raw score equals total number of articulation errors.
Phonological Processing: The clinician will administer the core subtests of the Comprehensive Test of Phonological Processing (CTOPP) to assess the client’s phonological processing skills in the following areas: phonological awareness, phonological memory, and rapid naming. Supplemental subtests will be administered if additional diagnostic information is needed. This area was not assessed during this session due to time constraints. | TT |
09/17/25 | A: The client obtained a raw score of 0 on the GFTA-2 which indicates that the client did not produce any articulation errors; because the client did not produce any articulation errors, the client does not require any articulation treatment. | TT |
09/17/25 | P: The clinician will continue the diagnostic process until phonological processing has been formally assessed with adequate and useful results. | TT |
Raw Score* | Standard Score | Confidence Interval 90% | Percentile | Test-Age Equivalent |
0 | 105 | 100 – 110 | > 56 | 7.8 |
IV: Progress Notes �(SOAP notes): Weekly, 2x/wk
DATES | PROGRESS NOTES | INITIALS |
9/17/25 9/19/25 | S: There is no data to report. The clinic was closed due to inclement weather. The client and her mother arrived to the session a few minutes late. The client’s mother informed the clinician that Z.B. was feeling a little sick, yet the client still seemed ready to begin the session. | BC |
9/17/25 9/19/25 | O: There is no data to report. The clinic was closed due to inclement weather.
The following objectives were addressed: Objective 1a. The client will be able to use the pronouns, them/those, in 1) sentences and 2) conversational speech without cues with 80% accuracy. The clinician presented the client with a 12 question worksheet on the pronouns them/those. The clinician instructed the client to complete the sentences by filling in the blanks. The client achieved 58% accuracy (7/12) independently and 100% accuracy with cues.
Objective 1b. The client will use twenty regular past tense forms of verbs in 1) sentences and 2) conversational speech without cues, with 80% accuracy. The clinician presented the client with a 12 question worksheet on regular past tense forms of verbs. The clinician instructed the client to complete the sentences by filling in the blanks. The client achieved 100% accuracy (12/12) independently.
Objective 2a. The client will use ten irregular past tense forms of verbs in 1) sentences and 2) conversational speech without cues, with 80% accuracy. The clinician presented the client with an 8 question worksheet on irregular past tense forms of verbs. The clinician instructed the client to complete the sentences by filling in the blanks. The client achieved 75% accuracy (6/8) independently and 100% accuracy (8/8) with cues.
Objective 2b. The client will correctly produce the /sh/ sound in all positions of words at the 1) phrase and 2) sentence level with cues, with 80% accuracy. This activity was started but not completed due to time constraints. There is no data to report at this time. | BC |
9/17/25 9/19/25 | A: There is no data to report. The clinic was closed due to inclement weather. The client did well on all of the activities presented to her. She excelled in the activity on regular past tense forms of verbs, scoring 100% accuracy without cues. Towards the end of the session the client’s accuracy seemed to decrease as if she was tired. The client stretched and yawned which also indicated such. | B.C. |
9/17/25 9/19/25 | P: There is no data to report. The clinic was closed due to inclement weather. The clinician will continue to follow the activities on the lesson plan and incorporate a break time for the client so she can stretch and become more focused during the second half of the session. | B.C. |
IV: Progress Notes �(SOAP notes): Absent
DATES | PROGRESS NOTES | INITIALS |
9/17/25 9/19/25 | S: The client’s caregiver cancelled this date due to car trouble. The client indicated that she will attempt to make the session on Wednesday of this week. The client’s caregiver called to cancel therapy today. She reported that she is unable to bring KT because her vehicle is being repaired. | AG |
9/17/25 & 9/19/25 | O: NA | AG |
9/17/25 & 9/19/25 | A: NA | AG |
9/17/25 & 9/19/25 | P: The clinician will continue with baselining activities for next week, per approved lesson plan.
| AG |
IV: Progress Notes �(SOAP notes): Absence d/t Holiday Observance
DATES | PROGRESS NOTES | INITIALS |
2/15/25 & 2/17/25 | S: The client will not attend therapy this week, due to the university’s observance of Spring Break. | AG |
2/15/25 & 2/17/25 | O: NA | AG |
2/15/25 & 2/17/25 | A: NA | AG |
2/15/25 & 2/17/25 | P: The clinician will continue to target goals included on the designated lesson plan. It may be advantageous to obtain another writing sample.
| AG |
Editing Procedures
Review Tips for Proofreading Clinical Reports
Roth and Worthington, 6th Edition (2021).
�
?Proofreading Questions?
Clinical Reports Overview
Professional Correspondence:
❖ Should be written clearly and concisely
❖ Correct grammar, spelling, and punctuation
❖ Usually includes such things as release of info, making referrals to other professionals, acknowledging referrals to colleagues
❖ It is essential that clients authorize the release of info – cannot give out info verbally or in writing without release
(Roth and Worthington, 2024)