SOAP WITH TREATMENT PSYCHOTHERAPY

Current Psychotherapy [textarea] psych/ med Mgmt 
psych Hospitalizations 
Php/Partial Hospitalization 
Outpatient Tx 
Family Member Had Outpatient Psychotherapy 
Individual & Group MH Evaluation & Tx (Psychotherapy) 
Rehab/Other Therapies 
Behavioral Health Austism Spectrum Disorder, Aba Services 
Crisis Intervention 
Counseling From Therapist At Primary Care Clinic 
Psychological Testing To Evaluate MH Condition 
MH & etoh Use Screening & Counseling (Screening, Brief Intervention, Referral, & Tx, “Sbirt”) 
psych Consultation 
Individual & Group MH 
Recreational [/textarea]
Focus Of Psychotherapy:[textarea] Interpersonal Conflict
Emotional Experience Related To Dx
Identification Of Coping Mechanisms
Grief Counseling [/textarea] 
Modality: [textarea] Insight Oriented
Supportive
Behavioral Modification [/textarea] 
Prior tx: [textarea] Psychotherapy
 med & Psychotherapy
Long Term Psychotherapy
Short Term Psychotherapy
Supportive Psychotherapy
Psychodynamic Psychotherapy
Cognitive Behavioral Therapy /CBT 
 Dialectical Behavior Therapy Skills Training
Drama Psychotherapy
Existential Psychotherapy
Exposure & Response Prevention Therapy
 Cognitive Processing Therapy
 -Centered Therapy [/textarea] 
VERBS [textarea] Asked
 Discussed consequences
 Examined benefits/consequences
 Gave Homework:
 Inquired about
 Led in practicing
 Listened Closely 
Affirmed
 Paraphrazed
 Pointed out
 Provided insight
 Questioned openly
 Reframed
 Responded to
 Validated
 Monitored
 Maintained
 offered feedback
 analyzed
 reality tested
 examined
 re-framed
 role-modeled
 consulted
 supported
 demonstrated
 Clarified / sought clarification
Assisted in 
 Contracted
 Gave homework assignment
 Reinforced
 Summarized
 Paraphrased
 Pointed out consequences
 Validated ’s point of view / feelings 
 Examined benefits / consequences
 Questioned (openly)
 Led in practicing [/textarea]
COMMON [textarea] conducted mental status exam
 modeled _ technique
 used _ exercise
modeled technique
 used exercise
 helped reflect on progress made so far on
 coached on
 Addressed concerns
 help feel more
 ensure access services
 Monitoring progress[/textarea] 
Active Listening/Rapport Building[textarea] Empathic responses to promote safety, expression of material & development of rapport
 Attentive listening, open-ended questions to facilitate expression of material
 help articulate feelings about
 encourage to share thoughts around
 used open ended questions
 Validated point of view feelings
 Engaged in positive social interaction
 Provided active listening
 asked open ended question to explore hx[/textarea]
Exploration of [textarea] Coping Patterns
Emotions
Relationship Patterns [/textarea]
Psychoeducation[textarea] Psycho-educational techniques rendered to assist  in better understanding of
 educated
 Education about how sx problem behaviors might be managed [/textarea]
MI[textarea]  utilized MI  techniques to increase motivation to change
 MI  techniques to assist in identification of available solutions & adaptive problem-solving 
 MI  techniques to help  identify obstacles & opportunities for change [/textarea] CBT  [textarea] Utilize CBT  techniques to assist  in challenging anxiety & agoraphobia
 Use Cognitive Restructuring techniques to re-frame challenges & difficult feelings to positive outlooks for self
 identifying anxiety provoking trigger
 Redirect to healthy cognition & behavior
 assist in Identify unhealthy cognition & behavior [/textarea] 
BEHAVIORAL [textarea] acknowledged success in
 reviewed current coping w/ 
 help practice appropriate behavior in
 Commended
 Prompted [/textarea] MINDFULNESS/COPING SKILLS [textarea] encouraged to practice "STOP BREATHE THINK" before making impulsive decision
 utilized mindfulness techniques w/ to help calm down
 learn to better manage
 assisted in making backup plan for reinforced current plan, including taking walks calling friends watching funny movies when in crisis to decrease feelings of hopelessness anxiety
 utilized mindfullness techniques
 ensure has sufficient support
 Led in practicing  [/textarea] INTERPERSONAL [textarea] practiced assertive communication skills to increase interpersonal effectiveness
 assist in developing assertive communication skills & implementing boundaries in relationships
 modeled appropriate communication skills[/textarea] PROBLEM SOLVING[textarea] worked to identify long term goals & assisted in identifying priorities & how to help get there
 assisted in identifying wants vs needs in planning for priorities
 modeled problem solving steps to to help decide best way to
 discussed triggers that caused setbacks, such as
 assist in achieving goals
 Assisted in developing
 Brainstormed w/ 
 help make plan around
 help overcome obstacles [/textarea]
[textarea name="variable_1" default="psychodynamic]
 [textarea] med MGMT
 educated about meds & how can reduce sx of RISK MGMT [/textarea] [textarea] educated about risks & consequences of current choices[/textarea]
Psycho-Social Interventions: [textarea]  Art Therapy
Behavior Modification
CBT / Cognitive Therapy; Behavioral Therapy
Choice Making
Cognitive Challenging / Refocusing / Reframing
Cognitive Processing Tx
Coping
Couple Therapy
Crisis Intervention
Day Tx Program
DBT 
Desensitization
Dialectical Behavior Tx Skills Training
Ego-State Therapy
Emdr
Emotion-Focused Therapy
Exposure & Response Prevention Tx
Family Therapy
Family Tx
Grief Work
Group Therapy
Guided Imagery
Hypnosis
Individual Therapy
Interactive Feedback
Interpersonal Resolutions
Interpersonal Rhythm Social Therapy
IPT 
Journaling Homework
Limit Setting
Logotherapy
Meditation
Mindfulness
Mindfulness CBT 
Mindfulness Training
Play Tx
Positive Reinforcement
Preventative Services
Psychoanalysis
Rapport Building
Reading Homework
Reality Testing
Redirection
Reframing
Relaxation Therapy
Short Term Psychodynamic
Skills/Relaxation Training
Solution Focused
Supportive Interaction
Supportive Therapy
Supportive Tx
Sx Mgmt/Coping
Transfer Financial Capicity
Transfer Tx Capacity
Transference Focused Therapy
Vocational Training [/textarea] Measurable Objectives Include: [textarea] Decrease in suicidality & self harm
Process grief w/ increased painful affect
Identification of early signs of decompensation of psych condition [/textarea]
Work on [textarea] initiating new relationships
assertiveness
improved communication in relationships
intimacy
self esteem regulation
socialization (including utilizing social supports) [/textarea] Psychotherapy Homework [textarea] Behavioral activation homework: [specify]
Behavioral experiment homework: [specify]
Cognitive restructuring homework: [specify]
Exposure therapy homework: [specify]
Journaling homework: [specify]
Self monitoring homework: [specify] [/textarea]

sleep hygiene discussed including
[checklist name="variable_1" value="establishing regular relaxing bedtime routine|exposure to sunlight during day, as well as darkness at night|limiting screen time before going to bed|exercise during day|impact of substance use on sleep"] 
discussed ways to better manage finances:
[checkbox name="variable_1" value="have spending plan or budget|track monthly spending|prioritizing spending on groceries, personal care items"] 
education provided 
[checkbox name="variable_1" value="re: health benefits of socialization & ways to improve socialization including forcing self to go out even when don't want|to practice conversation starters|option B|option C"]
nutrition discussed including 
[checkbox name="variable_1" value="role of nutrition in mental well-being|heart healthy diet|importance of including variety of fruits & vegetables|limiting or eliminating processed food & sweetened beverages"]

[checkbox name="variable_1" value="Demonstrated Active Listening Skills"]

[checklist name="variable_1" value="Used Reflection, & Clarified Priorities & Readiness|Used  Collaborative Approach To Agenda Map| 
Identifying 

[checklist name="variable_1" value="option A|option B|option C"]Used Open-Ended Questions To Assist In Exploring Problem Further, | Assessed Understanding & Previous Barriers. |Provided Affirmations & Built Confidence Through Ask-Tell-Ask, | Praise Given To Support 
[textarea name="variable_1" default="Praise: Specify At Least 1 Positive Event, Attitude Or Strength Of Identified"]

[textarea name="variable_1" default="Resources Provided:"]

[checklist name="variable_1" value="Mi Worksheet- Agenda Mapping.|Mi Worksheet- Exploring Pros & Cons|Mi Worksheet- Change Plan|List Of Community Resources For |Referral To |Phone Numbers For "]
[textarea name="variable_1" default="Specific Resources, Resources Not Listed, Or Indicate None"]

[checklist name="Interventions" 
Asked open ended questions|utilized reflective listening|conducted mental status exam|provided psychoeducation around|modeled technique|used exercise|Used motivational interviewing to increase motivation around"]

[textarea name="variable_1" default=""]
[checklist name="variable_1" 
behavior modification|cbt |choice making |client centered|communication skills |coping skills |crisis |crisis intervention|dbt|family/couples |flat |grief work |hallucinations |limit setting |mindfulness |motivational interviewing |parenting skills |positive reinforcement |problem solving |psychoeducation |rapport building |reality testing |redirection |reframing |relaxation training |role playing |stress reduction |structural family therapy |support linking |supportive interaction |telephone call|solution focused |support linking|supportive therapy|coping skills|validation| centered "]

[checklist name="to" 
In Order to...
|Reduce sx of
|help articulate feelings about
|encourage to share thoughts around
|help make plan around"]

Intervention details/Other Therapeutic Interventions Provided:  
Reviewed current and past functioning           
Developed treatment plan          
  Assessed risk of harm
Contracted for safety 
Discussed barriers to progress
Introduced parenting strategies
Evaluated progress toward treatment goals. 
Provided [link url="https://www.soapnote.org" memo="referral or linkage"]     
Provided 
[link url="https://www.soapnote.org" memo="Education and Information "]
Discussed alternative behaviors