Therapist Case Study Sample

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REASON
CHIEF COMPLAINT: Progress note for speech therapy.

S
Patient has participated in five speech therapy sessions since his last progress note. Therapist has utilized the code treatment with the music therapist x2 sessions. However, it has been felt that the music therapy is not helping him with his memory and it appears as though he needs more one-on-one support by the speech therapist to improve his problem-solving judgment, reasoning, and attention; therefore, co-treating with the music therapist has been discontinued at this time.

O
In general, patient is remembering to complete his homework. He has reported that he does not know how to ask questions. He feels like he is shy and has always been shy so has difficulty initiating and maintaining conversations, and he also reports that he can remember better if he can see the words to a song or in general versus through audition alone.

Status of Goals:

1. Patient will produce 15 or more items by category within 60 seconds to improve overall word finding abilities. Status: Therapist has not specifically addressed this goal during the past four weeks, therefore, goal ongoing. When asked to provide three items in more of an abstract concept, he was able to identify them with 90% accuracy. …show more content…
He will provide 10-15 words or phrases to describe a picture or an event in his immediate environment as well as a removed environment with minimal cues for overall initiation conversation and word retrieval during 5/5 trials. Status: Patient was told at one point that he was only producing 1-2 words to explain a situation and he reported he has been practicing starting at the beginning of the story, saying the middle of the story, and the end of the story. He has also been seen self-correcting himself during therapy sessions. At this time, the goal has been met; however, the therapist will continue to monitor
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