Whether you are a licensed clinical social worker or an MSW social worker, if you have a case load, chances are you need to write case notes: also referred to as progress notes.
If you are required to write your case notes in SOAP note format this post will give you an example of some of the most important components to include your SOAP note formated case note.
S: Subjective Data Includes –
- Clinically important statements made by client or family members attending session
- Statements may refer to feelings, thoughts, actions, treatment objectives, concerns
- Social worker may quote or summarizes clients statements, but does not assess or interpret statements in this section
O: Objective Data Includes – Counselor observations stated in measurable/factual and observable terms without interpretation
- Body language and facial expressions
- Physical appearance: hygiene, sick, well, tired, alert
- Test results or input form reports
A: Assessment – Counselor documents
- Assessment or understanding or hypothesis or synthesis of the S and O data
- Client’s progress made in session insights and understanding
- Family dynamics which impact client progress
P: Progress and /or plan – Counselor documents
- How client’s progress is being evaluated
- How clients symptoms have decreased, increased or renamed the same
- What changes client has made
- What the next steps are regarding treatment
Some other items a Social Worker should document in their case notes:
- Goal being addressed in session
- Risk assessment – whether there is any danger to self or others and what the plan for addressing is.
- Date and Time session begins and ends and length of session
- Progress towards discharge plan
- Any community support services needed or integrated into treatment
- Plan for and date of next session
- Stressors impacting treatment goals or progress
CLICK HERE To have a look at or to purchase a comprehensive set of Case Note Templates in SOAP and general format.