SOAP Note 3 SOAP_Note Instructions and Example-1.docxDownload SOAP_Note Instructions and Example-1.docx Students will watch the Netflix series MAID and write SOAP notes for certain episodes of the ser

SOAP Note Instructions

This assignment is designed to help you apply the theories we’re discussing in class to the show Maid. The purpose for this assignment is two-fold. First, this will help you to better understand the theories as you apply them to the family in the show. Second, future employers might ask you to complete SOAP notes on clients and this assignment can help you become familiar with developing them. Each section should be 1-2 paragraphs long. Citations are not required but grammar is very important.

Subjective (What is said): This section should be used to describe why the family members are visiting you. What is the purpose, from their point of view, to come to this session? What are 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. Use your imagination on what you would see based on how the characters interact with each other during the show): This section should be used to describe what occurred during the session from your point of view as the professional. It should describe in detail what each person’s experience was during the session from your perception. It is your “observation” of clients’ behaviors during the session. It should include both verbal and nonverbal information, for example, their eye contact, voice tone and volume, body posture, etc. Especially 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). Also 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, type of crisis, ethical check, crisis resolution stage, apply a crisis intervention model): This section should be used to assess what is occurring based on the crisis you have identified. You should assess for any issues that would carry ethical implications. This is your view of the client through the lens of the crisis, beyond what the client said or did. It includes continual evaluation of the client/family in terms of identifying the precipitating event, identifying cognitions and emotional distress, and identifying impairments in functioning – behaviorally, socially, academically, and occupationally. It also involves identification of themes and patterns that the client/family demonstrates and what stage of crisis resolution they are in. It is essential that you use the selected crisis and crisis intervention models to conceptualize the case. In other words, according to the crisis selected, explain how you make sense of what is occurring within this family system.

Plan (How will you provide support? Identify therapeutic interaction, past and present coping behavior, alternative strategies for coping, and identify (a list) of potential issues that the person might need to address if referred for counseling – and why. Some latitude will be given for interpretation): Based on the crisis, recommend a plan of action. What intervention will you use and why did you choose this? What has the client tried to do to help cope with the crisis? Offer alternatives strategies for coping with the crisis. Are there referrals to additional services you need to make? Why are you making these referrals? *Please note: Your plan should not look the same for each SOAP note and should be based on the crisis identified.

Where do I find assessment and plan information?

Assessment (Crisis application)

Nature of the crisis – Chapter 2

Type of crisis – Chapter 3

Ethical check – Chapter 2 & 4

Stage of family resolution of crisis – Chapter 3

Apply a crisis intervention model – Chapter 1 – 3

Plan (How will you provide support? Some latitude will be given for interpretation)

Identify therapeutic interaction – Chapter 2

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

SOAP Note

CLIENT (who is in crisis): Alex Russell

DATE OF SERVICE (date you met with/watched episode): 1/7/2022

TIME (time of day of appointment): 12:30pm

Subjective Data/Clinical Impressions: Ct. reports taking her daughter in the middle of the night and leaving her boyfriend. Ct. reports boyfriend “drinks to much”. Ct. reported sleeping in her car with her daughter. Ct reports no use of drugs or alcohol. Ct. reports being scared of boyfriend but reports “I’m not abused”. Ct. reports boyfriend has punched holes in the wall and thrown things at her. Ct. reports starting a job as a maid. Ct reports that her mom in unreliable and manic. Ct. reports daughter threw her doll from the car window and while pulled over to retrieve it her car gets hit but no one was hurt. Ct. reports having flashbacks of boyfriend punching the wall and throwing dishes. Ct. reports she is unable to work or have access to finances.

Objective Data/Behavioral Observations: Ct. presents for session with daughter. Ct. appears to be affectionate with daughter as evidenced by holding her and giving her kisses, hugs, and holding her hand. At one point ct. appears irritated as evidenced by her questions regarding finding housing and a job and her tone of the questions. Ct. uses curse words when speaking.

Assessment: The precipitating event bringing the ct. in was her boyfriend getting drunk and throwing things at her while the child was in the next room. Ct. is experiencing a pile up of crisis since leaving her relationship. Ct. doesn’t have housing, access to money to feed her and her child and is having difficulty finding a job. Ct appears to be suffering from PTSD symptoms as evidenced by flashbacks of boyfriend breaking dishes, punching the wall, and yelling at her. Ct. appears to be kept form working and doesn’t have access to finances. It appears cts. boyfriend makes all the decisions for her and ridicules and criticizes her. Ct. appears to be experiencing intimate partner violence. Ct. doesn’t report any thoughts of suicide or self-harm or any past or present child abuse. Ct. is in the survival stage of family resolution of the crisis.

Plan: Allow ct. to share her story while she processes through her crisis. Provide validating and empowering statements. Ct. has tried using support from her parents and she has a little support from both, but both appear to be unstable and/or inconsistent. Establish stable housing by referring ct. to a shelter which can also help with food and clothing needs. It will also be important to help the ct. find a stable source of income and establishment of job stability. Educate ct. on facts about battered women and the cycle of violence. Additionally, it will be important to establish a network of support for the ct. and her daughter. Finally, refer ct. to therapy for,

• Cognitive Behavioral Techniques to help manage stress and anger

• Explore her beliefs and values to make meaning of her crisis,

• Establish goals to help ct. identify a plan for her future,

Case Manager Signature: __Michelle Jeanfreau________ Degree: _BS_ Title: Case manager_ Date: 1/7/2022_