SOAP CASE NOTE

SOAP

• Subjective

• Objective

• Assessment

• Plan

Importance of documentation

• If its not written down, it didn’t happen​

• Adherence to professional ethics and standards.​

• Faulty memory​

• Needed to obtain accreditation or funding or revenue

• Defense in a lawsuit or dispute. Even personal notes can be subpoenaed​

• Documents build on one another chronologically​

• Assists in audits for best practice​

• Credibility​

• Facilitates coordination of services​

Documentation TIPs​

• Report what you see, hear, touch and observe

• Document strengths and weaknesses​

• DO NOT record an impression as fact.​

• Avoid professional or agency jargon​

• Refer to yourself as “this worker/this writer” instead of by “I” or your name​

• To document an omission or error, document it as a late entry and reference where the information should have been placed​

• Spell out acronyms or abbreviations the first time it’s used​

• Record your name and the date after every entry​

• Develop client goal/next session plan

Ethical Dilemmas​

• Ethical codes may be at odds with each other​

• Agency/institutional policies may conflict with the code ​

• Law and ethical codes may differ​

• Clinician’s morals may prevent compliance​

Ethical Decision Making​

• Involving the client in the process is essential​

• Consult with the supervisor or other senior colleagues​

• Professional Development​

• Do not Practice outside of the Scope of Social Work/your practice/beyond your competence

Ethical dilemmas occur when

social workers must choose among conflicting professional values, duties, and rights due to their competing obligations to clients, employers, colleagues, the social work profession, and society at large.​

Competence

• Need appropriate education and experience​

• Know the limits of your skills​

• Online interaction requires different skills​

• Accreditation​

• Professional License​

When using the Internet to deliver services:​

• Must be aware if can practice across state lines​

• It may not be covered by insurance​

• Must receive education and supervision on technology​

• Must ensure the privacy of transactions​

Informed Consent​

• Easily understood language​

• Clients must have the capacity to understand the information​

• Signed informed consent form (if there is one. Not all situations has it)​

• Client knows the benefits and risks

• Aware of options and other approaches​

• Balance of telling too much vs. too little​

  * Minors (guardians)​

  * Has to have the capacity to understand the information (not in sound mind, under the influence- not full consent)​

  Protect client rights and self determination​

Multiple Relationships​

• Prohibition of multiple relationships protects both the client and clinician ​

Can occur:​

• If the clinician has more than one professional role with a client (teacher and therapist)​

• If the clinician has both professional and personal relationships (counselor and friend, neighbor and therapist)​

• Limit relationships with those close to the client​

• Not all socializing is prohibited​

Confidentiality​

• Intended to ensure the privacy of client-clinician communication

• May breech confidentiality of client if “danger to self or others”, “abuse or neglect”​

• Duty to warn vs. duty to protect​

• to warn intended victims of any serious threat to their life or safety that is expressed by a client of the social worker. ​

• to protect clients from potential harm by notifying police or initiating involuntary commitment. ​

Limits on confidentiality

• Insurance companies​

• Work environment may limit​

• Courts can compel​

• Minors​

Release of information requires a signed form​

clinical record includes:

• Assessment data (including the reason the person has come for help, any test results, and social and medical history),

• Formulation (including diagnosis and goals for the work)

• Treatment plans (including progress toward goals)

  any forms completed by the client (including HIPAA documents and permission releases), reports received from other providers, and any reports about the client that are sent to anyone else, including reports to insurance carriers

The purpose of the clinical record is

• provide good care

• assist collaborating professionals in delivery of care

• ensure continuity of professional services in case of the (provider’s) injury, disability, or death or with a change of provider

• provide for supervision or training if relevant

• provide documentation required for reimbursement or required administratively under contracts or laws

• effectively document any decision making, especially in high-risk situations

• allow the (provider) to effectively answer a legal or regulatory complaint

progress notes

• included in clinical record

• updated after each client contact

Subjective

• What the client tells you about feelings, concerns, plans, goals, problems, relationships, using the client’s own words

• What others tell you about the client

Objective

What the clinician witnesses, appearance, affect, behaviors, strengths, Test reports or other information

Assessment

• Summarizes the clinician’s current thinking

• A synthesis and analysis of the subjective and objective portions of the note

Plan

Action plan, interventions used, progress, including plans for next meeting

clinician is required to record any contact with the client, whether that is

a session, phone call, letter, etc. Clinicians often do this by writing what have been called SOAP notes

Goal Setting

• The client and the clinician work toward setting goals that describe the desired outcomes of the working relationship

• goals should include desired outcomes that are observable and measurable and that can be used in assessing the effectiveness of interventions.

• Short-term goals: can be accomplished relatively quickly

• long-term goals: may take more time.

• negative goals: they would like to stop doing

• positive goals: they would like to work toward achieving

Example of Goal Outcomes

• To improve self-esteem and self-efficacy.

• Client will be able to express opinions and give feedback to others.

• Client will tolerate praise and positive feedback.

• Client will make more positive statements about self.

• Client will demonstrate increased eye contact with others.

• Client will identify positive talents and strengths about self.

• Client will increase the frequency of speaking with confidence both with the clinician and in social situations.

• Client will report a decreased fear of rejection.

• Client will increase statements of self-acceptance.

Specific and Concrete

goals have to be specific and concrete to provide clear directions for ensuing work together.

Partializing and Prioritizing Goals

• objectives: Clinicians help clients partialize goals; we help clients break major goals down into component parts

• partialize: break goals down into component parts.

• prioritize: rankingoals in the order of their urgency or importance

• Different stakeholders may have different goals

stakeholders

Friends, family, and others important to the client and to the problem-solving process, who have vested interests in the outcomes of the intervention.

Principles of Goal Setting

• Goals should be collaboratively constructed.

• Goals should be attainable.

• Goals should involve stakeholders in the discussion.

• Goals should be operationalized into observable behaviors so that both the clinician and client can tell when progress is being made.

• Goals should focus on positive actions not just the elimination of negatives.

• Goals should be partialized and, prioritized into manageable steps.

• Goals should specify the context in which the new behavior will occur.

• Goals should be constantly reviewed and revised in light of new information. The clinician and client should check in regularly to see how the client feels about the work and whether or not goals or objectives need to be changed.

• Good steps toward progress should be validated, and clients and clinicians should congratulate themselves about achievements