SOAP Note 1 SOAP_Note Instructions and Example-1.docx Students will watch the Netflix series MAID and write SOAP notes for certain episodes of the series. A SOAP note is a commonly used format often

SOAP Note

CLIENT (who is in crisis):

DATE OF SERVICE (date you met with/watched episode):

TIME (time of day of appointment):

Appearance

 Within Normal Limits (WNL)

 Unkempt

 Dirty

 Meticulous

Speech

 WNL

 Pressured

 Poverty of

 Impaired

 Slow

Mood/Affect

 WNL

 Flat

 Depressed

 Manic

 Anxious

Fearful

 Irritable

 Angry

 Labile

 Incongruent

Behavior

 WNL

 Guarded

 Withdrawn

 Defensive

 Oppositional

 Hostile

 Manipulative

 Impaired

 Threatening

 Impulsive

 Tearful

 Tired

Cognitions

 WNL

 Loose Assoc.

 Scattered

 Blocked

 Obsessive

 Paranoid

 Psychotic

Subjective Data/Clinical Impressions:

Objective Data/Behavioral Observations:

Assessment: (Apply a crisis intervention model – Chapter 1 – 3)

Nature of the crisis (Chapter 2 - precipitating event, cognitions, emotional distress, impairments in functioning (bx, social, academic, occupational)

Type of crisis (Chapter 3 - developmental, bolts from the blue, pile-up, exhaustion, perpetual, ambiguous loss)

Ethical check (Chapter 2 & 4 - suicide, homicide, psychosis, substance abuse, child/elder abuse)

Stage of family resolution of crisis (Chapter 3 - survival, adaptation, adjustment, spirituality)

Plan: (How will you provide support?)

Identify therapeutic interaction (Chapter 2 - validation, educational, empowering, and reframing statements)

Past and present coping behavior (Chapter 2)

Alternative strategies for coping (Chapter 1-3 & and chapter related to the crisis)

Identify (a list) of potential issues and dynamics of family intervention that the person might need to address if referred for counseling – and why (Chapter 3 and chapter related to the crisis-Roles, boundaries, communication, rules, values, goals)

Case Manager Signature: Degree: Title: Date: