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3 Apr

needs and goals for treatment/management


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SOAP Case NotesSubjectiveThe first step is to gather all the information the client has to share about theirexperience/symptoms. The client will tell you about their experience with the symptoms andcondition, as well as what they perceive to be their needs and goals fortreatment/management.The Subjective summary should include direct clients from the client. For example, a clientmight say, “I want to talk to my spouse about my anger.” The case worker would add thisverbatim quote. It’s crucial to record the client’s words, rather than paraphrasing them, so youcultivate the most accurate insight into their condition.The Subjective category is also an appropriate place to list any comments made by the client,their family members or their caretakers. This category is the basis for the rest of your notes aswell as your case plan, so getting the highest-quality information possible is paramount.ObjectiveThe Objective portion of a SOAP note includes factual information. It may include detailedobservations about the client’s appearance, behavior, body language, and mood. For example,you might write that the client arrived 15 minutes late to the session and slouched in the chair.Write details down as factually as possible. The Objective phase is only about raw data, notconclusions or diagnoses on your part. Record any measurable data during the client’s session,including applicable test scores.Documenting the Objective phase brings up the issue of separating symptoms from signs.Symptoms are the patient’s experience of their condition, whereas signs are objectiveobservations related to symptoms. If a client reports having symptoms of anxiety, such as panicattacks, signs of that anxiety might include visible trembling or clenching of muscles, as well ashypertension, determined by a physical test.You have a limited window for assessment, so it’s crucial to actively look for any signs thatcomplement or contradict information given in the Subjective section of the notes.AssessmentBoth the Subjective and Objective elements previously recorded come into effect in theAssessment phase. You will document your impressions and make interpretations based on theinformation you’ve gathered. For an initial visit, the Assessment portion of your notes may notbe concrete, and will develop when you obtain further information.For follow-up visits, the Assessment portion of SOAP notes covers an evaluation of how theclient is progressing toward established treatment/case plan goals. The Assessment will informyour current case plan as well as future plans, depending on whether the client is responding totreatment as expected. It’s essential to reflect on whether your client is showing improvement,maintaining improvements already made, worsening or demonstrating patterns of remission.Like the other sections of SOAP notes, your Assessment should only contain as muchinformation as is necessary. Some Assessments will be significantly longer than others, based onthe complexity of the client’s condition. Sometimes this section of your notes will contain only afew snippets of information like, “Client is being active, no change in the incidence of panicattacks.” In other situations, there are more pieces to evaluate, and the Assessment portion ofyour notes should extend to include all the appropriate information.PlanThis is where the previous three sections all come together to help you determine the course offuture action. The Plan section of your SOAP notes should contain information on:• Case plan goals and reasons for• The client’s immediate response (thoughts and feelings) to the case plan/treatment• When the client’s next appointment will be• Any instructions you gave the client, including homework tasks• Goals and outcome measures for new problems or problems being re-assessedYour Plan notes should include actionable items for each area of life the client wishes to workon. If your client is experiencing multiple concerns, such as post-traumatic stress disorder, incombination with a substance use disorder, your notes should include separate plans for eachcondition.The goal of this section is to address all the specific deficits listed in the Assessment. When doneefficiently, the Plan sets a clear roadmap for the client’s continuing treatment/intervention andprovides a window of insight for other professionals to continue that treatment/intervention ifneed be. Consult the Plan on each new visit, and adjust it regularly based on the findings in theAssessment section.

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