SOAP Note - Laurie - practice writing soap notes / documentation --- lecturer - Jeffrey Tomlinson PDF

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practice writing soap notes / documentation --- lecturer - Jeffrey Tomlinson...

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SOAP Note: LOIS S= Subjective: Info obtained from the client - reveals limitations, concerns, and problems. Use client’s words, paraphrase, or use family if person cannot speak. Be concise.  S1= Lois reports increasing stress, manic symptoms, use of substances and lack of daily routine “I don’t do anything anymore.”  S2= Lois reported feeling stressed, Pt. endorses: manic symptoms, use of substances and lack of daily routine. She stated “I don’t do anything anymore.”

Manic should be in the Assessment section Endorses means it was suggested to them and they are agreeing O= Objective: Record measurable, quantifiable, and observable data - present a picture of the intervention, describe what occurred.  O1= Lois has racing thoughts, changing topics, labile: alternating tearfulness and laughing inappropriately. She appears disheveled. She responded to guided deep breathing and was a able to engage in a 10 minute interview.  O2= Lois was seen for 30 minutes and participated in a 10 minute semi-structured initial contact interview. Pt demonstrated increased motor activity, rocking and hand wringing. Pt. responded to guided 5 minute 3 count, hold and release deep breathing exercise which assisted her to sit calmly. Pt had racing thoughts and labile mood as evidenced by changing topics and alternation from tearfulness to laughing inappropriately. Pt responded to redirection during the interview. Pt appeared disheveled: clothing soiled, hair unkempt. Pt responded positively to invitation to join a self care group on the unit tomorrow.

Appearance: use presents with Evidence to support what you think is happening  Like the pressure of speech and speed of speech supports your assessment that she is anxious Racing thoughts and labile mood should be in assessment A= Assessment: Therapist’s appraisal of the client's progress, functional limitations, and expected benefit from treatment (problem, progress, potential). Data to support assessment should be included in S & O above.  A1= Lois decompensated due to relapse, lack of structure and daily functional routine with antecedent stressors. Lois can benefit from treatment as she identifies wanting to change her lifestyle.  A2= Although client endorses situational stressors secondary to having to move out of her apartment and lack of a daily functional routine, she used maladaptive coping mechanisms: stopped her medication, binge drank alcohol and used K2. Pt has some insight into her mental illness, the antecedent events and the stressors that led to decomposition. Is motivated to make a lifestyle change which are indicators that she has potential to benefit from treatment. o MOHO P= Plan: The actual interventions that will be used to achieve goals. (Note: Interventions are achieved through OT activities and/or groups that are specific to the needs of the client.)  P1=Lois will engage in a structured daily routine including self care activities and practice relaxation techniques to manage and moderate the effects of symptoms.  P2= Pt will be encouraged to attend 1 OT groups on the unit daily to: (1) re-establish a functional routine including self care management, hygiene and medication management in order to set up a schedule (2)identify and utilize stress management techniques via skilled instruction to cope with effects of daily stressors more effectively.

Do not write STG/LTG, that’s in your treatment plan...