Social Workers: Easy way to write SOAP Notes

CLICK HERE to Download SOAP Note http://www.soapnoteexample.com/

Whether you are a licensed clinical social worker or an MSW social worker, if you have a case load, chances are you need to write case notes: also referred to as progress notes.

If you are required to write your case notes in SOAP note format this post will give you an example of some of the most important components to include your SOAP note formatted case note.

S: Subjective Data Includes -

Clinically important statements made by client or family members attending session
Statements may refer to feelings, thoughts, actions, treatment objectives, concerns
Social worker may quote or summarizes clients statements, but does not assess or interpret statements in this section

O: Objective Data Includes – Counselor observations stated in measurable/factual and observable terms without interpretation

Body language and facial expressions
Physical appearance: hygiene, sick, well, tired, alert
Test results or input form reports
Activities/actions

A: Assessment – Counselor documents

Assessment or understanding or hypothesis or synthesis of the S and O data
Client’s progress made in session insights and understanding
Family dynamics which impact client progress

P: Progress and /or plan – Counselor documents

How client’s progress is being evaluated
How clients symptoms have decreased, increased or renamed the same
What changes client has made
What the next steps are regarding treatment

Some other items a Social Worker should document in their case notes:

Goal being addressed in session
Risk assessment – whether there is any danger to self or others and what the plan for addressing is.
Date and Time session begins and ends and length of session
Progress towards discharge plan
Any community support services needed or integrated into treatment
Plan for and date of next session
Stressors impacting treatment goals or progress

CLICK HERE http://www.soapnoteexample.com/ To have a look at or to purchase a comprehensive set of Case Note Templates in SOAP and general format.

Видео Social Workers: Easy way to write SOAP Notes канала Counseling Forms