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 Checklist
Subjective (What is said):
What is the purpose, from their point of view, to come to this session?
What is their presenting problem(s) or issue(s)? This may be through one family member’s lens but should include everyone’s perspective.
Describe what the client says about causes, duration, and seriousness of issue(s).
How does the family understand the problem and what kind of help is being sought?
If the family has more than one concern, rank them based on the family’s perception of their importance.
Objective (What you see):
Described what occurred during the session from your point of view as the professional
“Observation” of clients’ behaviors during the session.
Both verbal and nonverbal information (for example, their eye contact, voice tone and volume, body posture, etc.)
Note any changes and when they occur (such as a client who becomes restless in discussing a topic or whose face turns red under certain circumstances).
Note discrepancies in behavior.
This section can also include information from other sources that have interactions with the client (teacher, guidance counselor, physician, etc.).
Assessment (Crisis application):
Nature of the crisis, also name the crisis here (PTSD, IPV, etc). (Precipitating event, cognitions, emotional distress, impairments in function – behavior, social, academic, occupational)
Type of crisis
Ethical check
Stage of family resolution of crisis
Apply a crisis intervention model
Identified themes and patterns that the client/family demonstrates
Explained how I made sense of the client/family according to the crisis occurring
Plan (How will you provide support?):
Identified therapeutic interaction & why I choose it
Recommended alternative strategies for coping based on specific crisis identified
Identified (a list) of potential issues and dynamics of family intervention that the person might need to address if referred for counseling – and why.
I discussed what the client tried to do to help cope with the crisis in the past and/or what they are doing currently.
I offered alternatives strategies for coping for the specific crisis (PTSD, IPV).
I made referrals to additional services and discussed why I was making these referrals.
My plan was based on the specific crisis identified in the assessment.
