Students may be asked to write brief narratives that reflect their own experiences that may have led to developing interest in the Human Service field. Personal Reflections may be in narrative form, or the instructor may have a particular format in mind and will guide students through assignments.
Treatment Plans/ Advocacy Plans/ Interventions: these are typically represented by Case Notes or “Soap” Notes as follows:
How to Write Psychotherapy Case Notes in SOAP Format
By Samantha Volz, eHow Contributor
To effectively treat patients, doctors, counselors and therapists struggle to understand the needs and concerns of each person they see. This understanding can grow more difficult if a patient sees multiple counselors, because each counselor may have his own opinion of the patient's wants or needs. One solution to this problem is for the counselors to use the SOAP format for taking notes. SOAP stands for subjective, objective, assessment and plan, and according to the Journal of Counseling and Development, this format allows for precise documentation and for holistic expression of needs and concerns of each patient.
- Start the notes with the date and time of the patient's interview or assessment, as well as the patient's personal information, including name, contact information, sex, age and emergency contact person.
- Complete the subjective section of the notes with information that the patient has related directly to you. This section includes opinion-based information from the patient: his feelings, concerns, goals for his therapy, etc. Include pertinent comments from friends, family, case workers or other people close to the patient.
- Write only fact-based information in the objective section of the notes. This information includes quantitative, verifiable evidence, such as what can be directly observed by the five senses and by scientific measurements. This can include the patient's appearance, any medical measurements taken and obvious behavior.
- Analyze the patient's behavior and problems in the assessment section of the notes. This section is often used to speculate a mental diagnosis or potential problems by combining the information from the first two sections and analyzing it with professional thinking.
- Create a plan for the patient's treatment and record it in the final section of your SOAP notes. This section often includes the date and time of the patient's next appointment, recommendations for interventions or notes of interventions attempted in the current session and a list of probable gains or goals based on the diagnosis and the client's attitude toward therapy.
When completing the subjective section of the SOAP, keep direct quotes to a minimum. You should paraphrase in order to best convey the patient's information in a brief assessment. Only include direct quotes if they pertain to potential harm for the patient or the people around him, or if they indicate a significant shift in mental state.
Many counselors use the phrase "as evidenced by" when documenting objective observations in order to back up their facts. The assessment section often includes "clinical impressions," which are a counselor's unofficial diagnosis or notes on what diagnoses to rule out during the patient's care. These must be carefully monitored, and always backed up with objective information, so that the counselor does not appear unprofessional.
Journal of Counseling and Development: SOAP Notes