In the brief presentation on SOAP Note Format we will:
- Discuss the differences between Subjective and Objective data
- Show concrete examples of subjective and objective data
- Help you gain confidence using SOAP format
Paper work can be a drag, being better informed about clinical note writing like SOAP format and having a quality form makes your job easier.
SOAP is a very popular format Mental Health use to document important details from the client’s session.
Subjective data is what the client: States, reports, complains of, describes etc. this is the clients viewpoint.
Examples of subjective data a clinician might record are:
- The client stated he is feeling much less depressed than when he began counseling
- The client reports she feels nauseas after taking her depression medication
- The client complained of feeling unmotivated to look for a job
- The client described having a loud argument with her husband and shared this often happens when they have been drinking alcohol.
- Client described feeling anxious and scared this morning while driving to therapy
Take away tip: subjective data has to do with what the client shares, reports, describes or otherwise expresses.
It’s not always easy to determine the difference between what is subjective and what is objective. One way to understand the differences is the objective data is the therapist’s observable, measurable and factual contribution.
Examples of objective data a clinician might record are:
- Mental health and mood status
- Client’s Motivation
- Client Behavior
- Physical health
- Emotions and affect
- Level of functioning
- Personality issues
Many of the same criteria used in your DSM V diagnosis are the focus of the SOAP assessment.
Examples of assessment data a clinician might record are:
- Client was motivated to accomplish goals as evidenced by completion of homework assignment
- Client wrung hands throughout session
- Client was experiencing a headache during the session
- Client’s emotions were labile – he swung from inappropriate laughing to crying.
Take away tip: Remember the Objective data is mainly measurable and observable.
The Assessment is where the therapist brings it all together and expresses his thoughts about what is going on with the client, based on the S and the O. Some therapist also use this space to update the DSM diagnosis or to Rule out or rule in a diagnosis.
In any case, if there is a formal diagnosis the assessment should certainly tie into the formal diagnosis. If one is using formal DSM diagnoses there must be enough evidence in the client assessment portions of the chart to support the diagnoses. Also, in focusing on the assessment portion of the clinical note will help the therapist to keep track of and record any mental health criteria changes.
When writing the assessment it is a good time to ask yourself if the client still meets the diagnostic criteria. Does the data support the diagnosis. The assessment should focus on those criteria that contribute to understanding the problem better and/or reaching an appropriate and accurate diagnosis.
For example the clinician might write under assessment:
- Client continues to experience depression NOS
- Client has occupational and family stressors
- Client expressing inappropriate anger
- Client exceptionally fearful of being abandoned
- Client test results showed hypothyroidism
Take away tip: Remember the Assessment is where you make sense of and assimilate the subjective and objective data.
The Plan essentially is the action steps and/or the clinical interventions. It is presumably the plan and clinical interventions that drive treatment forward and encourage the client to meet their goals and objectives.
Under the Plan section of the SOAP the therapist might write things like:
- That both the client and counselor are committed to doing, i.e. the client rescheduled for following week
- Plus interventions: The client is committed to attending the domestic violence support group
- Therapist will continue EMDR and biblio-therapy
- Next session therapist will use guided meditation and assist client in learning relaxation skills.
- Other interventions such as nutritional, medical or physical fitness interventions and the like that contribute to the clients therapeutic goals and objectives should be noted.
Take away tip: Remember the Plan is essentially a record of the action you and your client are committed to taking.
In Summary, remember to review SOAP note format tips regularly. The more confidant you are in how to document your sessions, the easier and more enjoyable this part of your job will be. Plus and most importantly the SOAP format will help you to stay focused on what is therapeutically important.
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