Case situation: You are a social worker at the Department of Human Resources. You arrive at the home of Mrs. Smith (Mother), who has a history of mental illness, a disheveled appearance, and is tearful. She has one child, age 9, and is in the middle of child custody proceedings, has recen

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Case situation: You are a social worker at the Department of Human Resources. You arrive at the home of Mrs. Smith (Mother), who has a history of mental illness, a disheveled appearance, and is tearful. She has one child, age 9, and is in the middle of child custody proceedings, has recently lost her job, and is hopeless. An the initial meeting with the boys father Mr. Smith, the worker exchanges introductions and describes a purpose and a role. Mr. Smith discloses he is fearful his wife may hurt herself or her son. (From this point on you can make any information you desire for this family)

Description Lab 3, you are responsible for completing a Soap Note on the Smith Scenario you have been working on all semester. This will be a culmination of all the visits you have had thus far with Smiths. (If you chose a different case situation you will use that case situation to create at soap note). Remember this is a practice of legal documentation so it should contact facts and paint of picture of the work your doing.

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HOW TO WRITE A SOAP NOTE SOAP stands for “subjective, objective, assessment, plan”–providing a standardized method of taking notes. SOAP notes are used by many professionals including social workers, physicians, counselors and psychiatrists. SOAP notes were first developed in 1964 as a means of providing accurate records of a patient’s history, case details, prognosis, treatment and results. Through the use of each of the four areas in this record-keeping method, a social worker documents initial problems, steps taken to resolve the problem and the final results of these treatment steps. 1. S–Complete the subjective portion of the SOAP notes based on information obtained from the client. This should focus on the problem that brought the client in contact with the social worker, how the client understands the problem, how it affects his life and what he hopes to find in regard to help or treatment. This portion includes all relevant information provided by the client but should remain as brief and direct as possible. It may also include information from other people including doctors, family members or neighbors. 2. O–Write the objective portion of the notes to include all factual information. This covers both the social worker’s personal observations of the client and any objective information from outside sources such as medical reports or the results of psychiatric testing. Avoid making judgments or using labels to describe the client. 3. A–Include your professional opinion in the assessment portion of the SOAP notes. This involves taking the information provided in the first two sections and using it to draw a final conclusion on the problem and the needs of the client. The assessment should also note possible areas of further inquiry or testing to guide proper treatment of the individual or family members. 4. P-Describe final recommendations or treatment to be used by the client in the plan section of the SOAP notes. This may include information such as referrals to outside agencies or consultations needed by the social worker with another professional regarding the client. Final decisions regarding the next steps to take, including dismissal from any further proceedings, should be noted in this section. Tips & Warnings • Record information during or immediately following meetings with the client to ensure accuracy of the records. • If not typed, write all SOAP notes in black pen for ease of reading and photocopying. • Leave no blank space between sections of the report and avoid writing in margins or adding additional information later on. This can be used in later court proceedings to question the validity of the report.

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