Clinical Writing, Goal Setting and Treatment Planning

Types of Documentation SOAP notes (subjective, objective, assessment, plan) DAP notes (data, assessment, plan) Phone calls with cx or “collaterals” Summary note –Demographics –Primary problem(s)/reason for referral –Health concerns/treatment –Major psychosocial stressors –Important relevant relationships/supports –Primary goal(s) Letters/reports to court or service providers

Professional writing Use of language 1.Descriptive 2.Behavioral 3.Distinguishes facts from hypotheses 4.Brief and to the point. Watch “Amanda”, write a SOAP or DAP note, then discuss

Example SOAP note S: Cx states she doesn’t see much chance for improving her life. O: Cx initially did not acknowledge a problem with using and argued with writer; later in the interview she appeared sad and hopeless that she can make positive changes. A: Cx appears to be using and this is negatively impacting her school work and relationship with parents. P: Writer will set up a meeting with parents and cx.

Example DAP note D: Cx was referred due to failing grade; she initially denied using substances but later acknowledged that she is using and feels hopeless to change the situation. A: Cx has relapsed and is not yet ready to commit to sobriety. P: Writer will meet with cx and her parents to discuss limit setting at home and progress in school.

What is a Treatment Plan? Intake/assessment results in an understanding of client needs. Problem list and corresponding goals are mutually agreed upon. Strategies to accomplish the goals are identified.

Goal setting: Goals should… 1.Be mutually agreed upon 2.State what will be achieved 3.Be within the client’s reach 4.Be measurable 5.Include a target date for completion.

Effective Treatment Plans 1.Explore and problem solve barriers to goal achievement. 2.Identify strategies logically linked to the goal. 3.Include when strategies will be completed. 4.Incorporate others as appropriate.