Expert answer:HN520 What Is Your Assessment? Soap Note

  

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When writing your SOAP note base the note off of the information provided to you. Make sure the diagnosis
fits the symptoms provided to you in the case materials. It is possible the initial/provisional diagnosis may
change as you know more about the client. This additional information about the client can come from the
client, family, friends, or other collateral sources. Of course a release of information would be required to
obtain collateral information. Diagnosis should be based from a holistic perspective, looking at multiple
aspects of the client’s life. For example has there been any recent changes in the client’s life (environment,
school, expectations, social/friends, family, and responsibilities). If yes, it is likely there could be issues with
adjusting.
I have included some informational resources about adjustment to college and the impact it can have.
https://www.psychologytoday.com/us/blog/theory-knowledge/201402/the-college-student-mental-health-crisis
https://copebetter.com/how-to-cope-with-adjustment-disorder/
https://counseling.dasa.ncsu.edu/adjusting-to-college/
DQ#5 In Topic 5, you created a treatment plan for your client. Create a SOAP note that would go in the client’s
chart following the visit. Post the SOAP note as a reply to this discussion thread. For follow-up discussion, evaluate
at least two of your peers’ SOAP notes. Would you have documented anything differently? Why or why not?
Reference: See what is a SOAP note?
DQ#2: In Topic 5, you created a treatment plan for your client. If your client was to attend a group therapy
session, write a progress note for that client’s participation in that group. How is writing a group progress note
different than an individual progress note?
Reference:
Read “Writing Progress Notes: 10 Do’s and Don’ts,” by Roth, from Current Psychiatry (2005).
URL:
http://www.mdedge.com/currentpsychiatry/article/59861/writing-progress-notes-10-dos-and-donts
What is a SOAP note?
A SOAP note is a form of written documentation many healthcare professions use to
record a patient or client interaction. Because SOAP notes are employed by a broad
range of fields with different patient/client care objectives, their ideal format can differ
substantially between fields, workplaces, and even within departments. However, all
SOAP notes should include Subjective, Objective, Assessment, and Plan sections,
hence the acronym SOAP. A SOAP note should convey information from a session that
the writer feels is relevant for other healthcare professionals to provide appropriate
treatment. The audience of SOAP notes generally consists of other healthcare providers
both within the writer’s own field as well in related fields but can also include readers
such as those associated with insurance companies and litigation. A good SOAP note
should result in improved quality of patient care by helping healthcare professionals
better document and therefore recall and apply details about a specific case.
How long is a SOAP note and how do I style one?
The length and style of a SOAP note will vary depending on one’s field, individual
workplace, and job requirements. SOAP notes can be written in full sentence paragraph
form or as an organized list of sentences fragments. Note the difference in style and
format in the following two examples. The first come from within a hospital context. The
second is an example from a mental health counseling setting.
Example #1
11/1/97
S – Nauseated, fatigued
O – Less jaundiced
Liver less tender
Taking adequate calories and fluid
Ultrasound liver/billary tract: normal
A – Seems to be improving
No obstruction
P – Check liver tests tomorrow
Phone laboratory for hepatitis markers
(from Heifferon, 2005, p. 103)
Example #2
7/7/01 2 p.m. (S) Reports counseling is not helping him get his family back. Insists the
use of violence has been needed to “straighten out” family members. Reports history of
domestic violence. Recent history: States he met and verbally fought with his wife
yesterday regarding the privileges of oldest child. Personal history: childhood physical
and mental abuse resulting in foster care placement, ages 11-18. (O) Generally agitated
throughout the session. Toward the end of the session stood up, with clenched fists and
jaw, angrily stated that counseling is “same old B.S.!” Rushed out of office. (A) Physical
Abuse of Adult [V61.1 DSM code] and Child(ren) [V61.21]. Clinical impressions: rule out
Intermittent Explosive Disorder given bouts of uncontrolled rage with non-specific
emotional trigger. (P) Rescheduled for 7/14/01 @ 2 p.m.; Continue cognitive therapy.
Refer to Men’s Alternatives to Violence Group.

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