6 SOAP Notes, SMART Goals & Treatment Plans

What does SMART stand for in this training?

Specific, Measurable, Assignable, Realistic, Time-bound.

What does 'Specific' mean in a SMART goal?

Clear enough to know when the behavior is happening or not.

What does 'Measurable' mean in a SMART goal?

Includes frequency, duration, or count.

What does 'Assignable' mean in this model?

Identify who else in the system can support success.

What does 'Realistic' mean in goal setting?

The goal should be step one, not step ten.

What does 'Time-bound' mean?

Includes a check-in timeline.

Why should SMART goals stand alone?

Anyone reading should understand the target behavior.

Why should therapists never copy-paste identical SMART goals?

It may be flagged as Medicaid fraud.

If continuing the same goal, what should be added?

Updated context based on today’s visit.

Why start goals near the client’s baseline?

Early success builds self-efficacy.

What does SOAP stand for?

Subjective, Objective, Assessment, Plan.

What belongs in the Subjective section?

What the client reported in their own words.

What phrases are recommended in Subjective notes?

'Client stated' or 'client reported.'

What belongs in the Objective section?

Therapist observations and assessment scores.

Name one observation that may go in Objective.

Affect, hygiene, energy, presentation.

Where should PHQ/GAD/SCARED scores be documented?

Objective section.

What belongs in the Assessment section?

Diagnosis, impressions, symptoms, systemic impact.

What phrase helps link symptoms to evidence?

'As evidenced by…'.

What belongs in the Plan section?

SMART goals and client action steps.

What should never be in the Plan section?

What the therapist will do next session.

Why is the Plan section important financially?

It influences reimbursement.

What should the Context section include?

Original presenting concern/referral reason.

How should notes be written legally?

As if the client and a lawyer may read them.

What ink color should be used for handwritten notes?

Black ink.

How should errors be corrected on handwritten notes?

Single line through error with initials.

How should unused sections be handled?

Diagonal line through section with initials.

What is low family inclusion?

Family is used mainly as an information source.

What is moderate family inclusion?

Family collaborates in helping solve the concern.

What is high family inclusion?

Explore how the child’s issue affects the whole system.

Example of high family inclusion question?

'How is the family affected by this bullying?'.

What level of inclusion should therapists aim for when possible?

Moderate to high.

If no collaboration occurs in session, what should be done?

Mark the section accordingly and initial it.

If a student transfers to a school without services, what must happen?

Provide three referral options.

Name one possible referral resource mentioned.

Pride, Integrated Family Services, ECU Family Therapy Clinic.

What should you do when arriving at school?

Greet front desk staff and check in.

What is 'completing the loop'?

Checking in with key staff (student services, principal, teachers).

Why repeat your name during introductions?

To help staff remember you.

What badge should be worn on site?

ECU One Card or approved badge.

What three documents are in the referral packet?

Referral form, behavioral health referral, parent consent.

For joint custody, whose signatures are needed?

Both parents.

What can be used if one parent is absent?

Timestamped verbal consent documentation.

What is the therapy agreement for?

Consent, confidentiality, and treatment participation.

Can young children sign if able to write their name?

Yes.

What does HIPAA protect?

Health information.

What does FERPA protect?

Educational records.

What is needed before sharing protected health information?

Authorization/release of information.

Why use broad wording like 'Eastern Elementary staff' on releases?

To avoid missing specific staff names.

Can parents revoke authorization?

Yes.

If someone not on the release shares info, what should you do?

Do not confirm or deny treatment relationship.

What is the exception to confidentiality limits?

Imminent danger/crisis situations.

What summer caseload target was recommended?

Around 20–25 students.

Why is summer considered valuable clinically?

Strong family commitment and major progress can happen.

Why is 5–6 summer clients considered too low?

Insufficient consistency and momentum.

When should treatment plans usually be completed?

Between sessions 3–4.

How many presenting concerns should a plan include?

1–3 concerns.

What timeframe should goals roughly cover?

About 3 months.

What should be documented at 3-month updates?

Improving, same, or worsening—with evidence.

How should completed goals be marked?

'Goal achieved' with initials and date.

How must client files be stored?

Double locked.

Should multiple clients’ notes be mixed in one folder?

No.

What should process notes avoid?

Identifying information.

Why keep process notes minimal and cryptic?

They can be subpoenaed.

What are encounter forms mainly for?

In-session note taking.

What does IEP stand for?

Individualized Education Program.

What law governs IEPs?

Individuals with Disabilities Education Act (IDEA).

Name one common IEP category.

Specific learning disability or speech/language impairment.

Who must be on the IEP team?

Guardian, teacher, special education teacher (minimum).

Can therapists attend IEP meetings?

Yes, with parent consent.

What should every IEP clearly state?

Current levels, goals, services, accommodations.

What law governs 504 plans?

Rehabilitation Act of 1973.

Who qualifies for a 504 plan?

A student with a disability affecting learning in general education.

How are 504 plans different from IEPs?

Broader and less standardized.

Why do supervisors observe sessions?

To assess competency and support growth.

Must every skill appear in every session?

No.

Why show supervisors challenging cases too?

They can provide coaching or co-therapy support.

What must be completed before getting keys/email/badge?

All clearance documents.

Can students shadow before full clearance?

Yes, but cannot practice independently.

What should email with parents mainly be used for?

Scheduling and paperwork.

Why avoid therapy via email?

Emails are part of the legal record.

If a parent sends a long clinical email, what should you say?

'Sounds like we need to have a phone call.'

What platform was named for telehealth?

Webex.

What future topics were mentioned?

Telehealth procedures and discharge planning.