Wk DQ 1 and 2
Wk DQ 1 and 2
Question description
Discussion Question 1 – DUE NOW
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?
This discussion question meets the following NASAC Standards:
70) Describe and document treatment process, progress, and outcome.
94) Describe and summarize client behavior within the group for the purpose of documenting the client’s progress and identifying needs/issues that may require modification of the treatment plan.
109) Demonstrate knowledge of accepted principles of client record management.
EXAMPLE OF HOW POST SHOULD BE BELOW:
Utilizing the SOAP information articles provided by Purdue OWL (2018), the following is the SOAP notes I would make on the patient, Eliza.
10/6/18 3pm
S : Cl reported she is only here because she got in trouble on campus. She stated that she was “only buzzed” during the incident. Cl denied having a problem with alcohol. When discussing the treatment plan with the client, she expressed indifference towards doing any work. Cl had struggled making friends and felt lonely. Cl states the only friends she has made take advantage of her kindness.
O : Cl attended a second session after demonstrating she did not want to be there. Cl listened to the treatment plan silently. She seemed uncomfortable during the session and did not talk often.
A : Cl does not have much motivation to continue counseling past the required amount of sessions. She is struggling with denial about her unhealthy alcohol use. Cl continues to engage in unhealthy friendships.
P : Continue with POC. Encourage cl to develop attainable goals for this week. Next appointment scheduled for 10/13/18 @ 3pm. Continue CBT. Refer cl to Celebrate Recovery group meeting.
Reference:
Purdue OWL. (2018). Soap notes. Purdue University . Retrieved from https://owl.purdue.edu/owl/subject_specific_writin…
Discussion Question 2 – DUE MONDAY October 8th
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?
This discussion question meets the following NASAC Standards:
70) Describe and document treatment process, progress, and outcome.
94) Describe and summarize client behavior within the group for the purpose of documenting the client’s progress and identifying needs/issues that may require modification of the treatment plan.
109) Demonstrate knowledge of accepted principles of client record management.
Learning to Write Case Notes Using the SOAP Format
Read “Learning to Write Case Notes Using the SOAP Format, by Ceron and Turtle-Song, from the Journal of Counseling & Development (2002).
4. SOAP Notes
Read “SOAP Notes,” located on the Owl Purdue website (2017).
https://owl.english.purdue.edu/owl/resource/1003/01/
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