Overview
For this discussion, select a case study you have not already chosen. Develop a summary of a counseling session that you might have with this client.
Then, use the SOAP Note Form multimedia piece to create the necessary clinical documentation to represent the summarized counseling session. Title and upload your SOAP note:
Subjective:
Client's reported feelings and/or subjective information which are clinically significant captured as a summary or sometimes as a direct quote from the client. Example: "Sometimes I get mad and act crazy."
Objective:
Include observable information or data that is connected to the client's subjective information. This data should be facts and will include issues addressed during session. Statements related to appearance, attitude, orientation, affect, mood may be placed in this section as well.
Assessment:
Clinical impressions and judgments connected back to (S) and (O), diagnosis (if applicable), prognosis, progress:
Plan:
Plans for future therapy session, any homework, referrals to outside resources. Example: Continue with individual and family work; make appointment to see physician; restrict socialization to family circle; structure time.