GET SOAP NOTES
Hi, I'm Jean LeStourgeon and I create forms and other tools that make mental health counselors work more easily.
At the end of this brief presentation on the tips to write SOAP notes, you will remove these three things:
# 1 thing to remember when I write SOAP Notes
A common mistake that counselors make when writing notes
How to help keep out of legal problems
Before starting, you should know that the forms do not have to be a necessary evil. They can and should be a dynamic guide that guides you and your clients successfully through the therapeutic process. These SOAP grade tips will help you to truly appreciate the need for a quality SOAP grade form.
Well, let's start … The first thing to remember when sitting down to write your SOAP notes is who your audience is.
Ask yourself: "Who will read this note?" "Who is the audience?"
A SOAP note becomes part of the client's chart, which is the clinical history. The therapist can keep the therapy notes as part of the chart, but the SOAP note we are talking about today is part of the record, which means that it could be viewed now or in the future as follows:
The client, other professionals who work with the client, a judge or lawyer
A very common mistake that counselors make is not to use a concise format when writing their notes and not being sufficiently familiar with the SOAP format to maintain themselves ethically, legally and professionally over the board. Here is a summary: frequent review tips on how to write a good SOAP note.
I do not know about you, but I always had trouble remembering what the acronym means and means.
Let's quickly review what SOAP means and we'll give you a simple example to help you understand and remember the meaning of each letter:
Remember that S means subjective. The subjective data are typically things that the client informed him, "Today I feel very tired and had problems getting out of bed". Subjective refers to data that is more like an opinion. Statements colored by perceptions, feelings and experiences.
The O means Goal. Things that the therapist observed about the client. The objective data are measurable and observable. The client kept closing his eyes and his head nodded. The medication was increased 1 week earlier.
The A refers to the Evaluation. His professional evaluation is based on what was reported and what he observed in the session, "The client seems to be over medicated."
The P refers to the Plan. The plan is the action that you and the client will take. In this case, call a family member to take the client home. Contact the clients MD immediately to analyze the symptoms and plan.
Can you see how to use and being familiar with the SOAP format will help you stay focused on what is important?
Here is another tip to take: before each session review your SOAP from the previous session. During the session, review the key points of your note with your client.
By doing this, the SOAP format drives forward processing.
You can also see how the use of your SOAP note format gives the therapist and your client responsibility: by adhering to the SOAP format you will be assured that you will keep the client focused on the sessions, keep up with the important aspects of the treatment and will collaborate with your client to ensure they see the progress they expected.
Because many therapists never request the citation of their pictures, do not work with assistant professionals who need access to their records and rarely have a client ask for a copy and relax asking the question each and every time they are asked. feel make a SOAP note "Who am I writing the note for? I am writing this for the medical record.
Ask yourself, if another professional read this SOAP note, would they get a clear picture of the client's symptoms, problems, evaluation and action plan? If the record is cited, it will protect the client and the therapist because it is clear, consistent, accurate and measurable. I am sure that at this time you can see how to have a good quality SOAP note with check boxes and guidelines to remind you to address issues such as risk assessment, medication management, mental status, evaluation and plan will help keep you professionally ethical and legally. above the board.
Always ask yourself, "Who am I writing this SOAP note for?"
Consider who could access or read the notes in the future
A good quality SOAP note guides you through the process of writing notes.
Video credits to Counseling Forms YouTube channel