Documentation

SOAP notes

• Subjective

• Objective

• Assessment

• Plan

Subjective

The clients perspective, feeling, and self reported info

• Will include direct quotes

Objective

Includes observations and measurable data from the social workers perspective

• Ex: if the client had poor hygiene or unsheveled clothes

Assessment

A combination of subjective and objective

• May include social work objective assessment and insight provided by the client

• Ex: “client may be experiencing distress about financials”

Plan

Outlines intended interventions and future steps

BIRP notes

• Behavior

• Intervention

• Response

• Plan

Behavior

Observable actions, reactions, responses, an body language

• Ex: crying, isolating themselves, yelling

Intervention

Services provided by the social worker in the session

• Ex: play therapy and reflective questioning

Response

The client response to interventions