SOAP ASSESSMENT
docx
keyboard_arrow_up
School
University of Maine, Augusta *
*We aren’t endorsed by this school
Course
212
Subject
Health Science
Date
Dec 6, 2023
Type
docx
Pages
2
Uploaded by EarlInternet12596
SOAP ASSESSMENT
Subjective: Bill stated he was experiencing cravings for cocaine frequently. The
client states wanting to leave his residential program and revert to Narcotics
Anonymous. The client states that he is now sober but is experiencing drug
dreams on a regular basis, causing him to wake up frequently and an inability
to fall back to sleep.
Objective: The client was on time for his appointment. He did not show signs of
intoxication but was easily distracted. This was indicated on multiple occasions
by asking me to repeat questions and by continually checking the time. The
client has lost weight and has a diminished interest in self-care and hygiene.
The client stated he has been too depressed to shower and his hair was
unkept. Bill's weight loss was indicated by Bill when talking about the results
of his recent physical. Bill spoke of his recent depression and took several
seconds to respond to questions I asked him during the session. The client
states that he lacks energy when completing everyday tasks.
Assessment: Client states that he has only relapsed once since the last session;
showing improvements in his relapse prevention strategies. Although he says
he would like to leave the residential program, he has no plans to do so soon.
Bill is building trust with the case manager and is opening up more about his
feelings. Bill can point out some strengths and weaknesses and looks forward
to overcoming his obstacles. Bill states his depression is worsening, and is
open to a referral for individualized counseling and a psychiatrist for
depression medication. Showering, proper meals, and an interest in personal
hygiene have become major obstacles for Bill.
Plan: CM will meet with Bill in two weeks for a further strength and need
assessment. CM will write a referral for individualized counseling and a referral
for intake with a staff psychiatrist. Client agrees to follow his safety plan if
needed. Bill agrees speak with his sponsor and be forthcoming about his
cravings. Bill agrees to continue his residential program until we meet to
discuss further alternatives.
Writing this assessment in a SOAP format was challenging for me. I fist wrote a
summary of the interaction and then placed the information in the assigned column. I
found that I was second guessing myself on what information went under what category
and after a review of my draft, I found I had put the information under a category in
which it better fit in a separate area. I can see the benefits in SOAP notes as they are a
clear and concise way to summarize an encounter with client. SOAP notes are also
regarded by positivepsychology.com as a way to “contribute to continuity of care and
are a tool for risk management and malpractice protection.” With more practice I can
see how writing and reviewing them will become easier. They are a tool that track’s a
client’s progress in an organized fashion.
Writing this assessment in SOAP format was challenging for me. I began by writing a
summary of the encounter and then entered the information into the appropriate
column. I discovered that I was second-guessing myself about what material belonged
to which category, and after a review of my draft, I discovered that I had placed the
information in a category when it would be better suited in a distinct section. SOAP
notes have the advantage of being a clear and sufficient way to summarize a client
experience. Positivepsychology.com considers SOAP notes to "contribute to continuity
of care and are a tool for risk management and malpractice protection." I believe that
with additional training, writing and reviewing them will become easier. They are a tool
that tracks a client's progress in an organized fashion.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help