The SOAPnote Project > Social Work > RR Checkbox Soap Note

RR Checkbox Soap Note

posted 2024-08-20, updated 2024-08-25

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MEDICATION
[checkbox name="meds" value="Client denies current prescription of medication(s).|Client reports no changes to prescribed medication(s).|Client reports changes to prescribed medication(s).|Therapist and clt did not discuss medication. Will continue to explore medication changes in future sessions|Client notes"] [textarea name="medchanges" default="enter notes here" rows="2"]

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SYMPTOMS AND SUBJECTIVE
Client reports doing [checkbox name="concerns" value="okay|better than last meeting|worse compared to last meeting|not so good"]. [textarea name="update" default=" " rows="2"]


Session Note(i.e. what happened in session, additional details on interventions used, client response, plan for next session)
Client reported [textarea name="variable_1" default="Enter context of session here"]    

[var name="firstname"] reports experiencing symptoms and/or has complaints about [checkbox name="variable1" value="anxiety/worry|depressed mood|sadness|loss of interest in pleasurable activities|tearful or crying spells|fatigue/low energy|difficulty sleeping|trouble falling asleep|appetite changes|difficulty concentrating|low motivation|poor academic/work performance|isolation from others|loneliness|low self-esteem|anxiety of social situations|concerns of negative evaluation by others|fear of embarrassing self|panic|intense fear/intense discomfort|worry about having future panic symptoms/attacks|muscle tension|difficulty controlling worry/excessive worrying|worry about job responsibilities|worry about health|worry about finances|panic    attacks|fear|hopelessness|impulsivity|hypervigilance|grief|worry about future of relationship|low self-confidence|interpersonal conflicts|irritability|emotional instability|Binging/purging | life transitions | role confusion | guild/shame | grief | OCD symptoms or behaviors  | lack of self care | poor impulse control | physical pain | intrusive thoughts | inability to make decisions | poor concentration | restlessness | trauma|other"]. [textarea name="sx" default=" "  rows="2"]




[var name="firstname"] discusses [checkbox name="variable4" value="symptom management|management of depression symptoms|management of anxiety symptoms|self-esteem|ADHD|friendships|childhood/family of origin|emotion dysregulation|anger issues|distress intolerance|an adjustment to a stressor(s)|grief/loss|relationship distress|relationship dissatisfaction|relationship argument or regrettable incident with partner|relationship intimacy concerns|interpersonal ineffectiveness/conflict|boundary setting|a conflict with peers|a conflict with family|a conflict with coworker(s)|self-care/hygiene issues|sleeping issues|physical activity/exercise|substance use concerns|alcohol use concerns|cannabis use concerns|nicotine use concerns|trauma|stressor(s)/coping mechanism(s)|familial relationship distress|employment issues|financial issues|legal issues|housing issues|parenting stress|medical/health concerns|medication concerns|religious/spiritual concerns|other"]. [textarea name="themes" default=" " rows="2"].





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OBJECTIVE
Met with [text name="firstname" default="Name"] [select name="mode" value="via TherapyNotes Telehealth Platform|via secure telehealth|in person"].  



Encounter type: [checklist name=encountertype value="Individual|Couples|Family|Extended Session|Crisis Session|Collateral without client present|individual with collateral"] [textarea name="who" default="specify who here"]


Major Themes
[checklist name="variable_1" value="Identity/Role Confusion | conflict in relationship | work/school problems | stressors/coping methods | childhood/family of origin | traumatic events | substance use | goals/treatment planning | grief processing | conflict with peer group | financial worries | housing instability  | recovering from divorce/breakup | new medical diagnosis | cognitive impairment/functioning  | sleep issues biopsychosocial assessment  |  other "]    [textarea name="variable_1" default="enter notes here"]




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Therapist [checkbox name="variable17" value="reviewed of homework|discussion of progress towards goals|provided psychological assessments|assisted with boundary setting|provided active and empathetic listening toward the client's thoughts and feelings|engaged using open-ended questions|stated normalization/validation of thoughts and feelings|conducted therapeutic rapport building|provided encouragement and reassurance|reviewed family history/dynamics|provided role-play exercises|assisted client in problem-solving|processed client's thoughts and feelings|identified negative coping mechanisms|provided psychoeducation about mindfulness and meditation|provided relaxation skills|provided psychoeducation|identified and challenged cognitive distortions|practiced cognitive restructuring|reviewed self-care activities|stated positive affirmations|identified and/or reviewed positive coping skills|reviewed and practiced effective communication skills and assertiveness techniques|elicited change talk|explored and reviewed effective parenting strategies|processed the aftermath of an argument or incident|explored patterns of closeness and distance in relationships|explored couple's communication cycles|observed and provided feedback on couple's communication and interactions|provided DBT/emotion regulation skills|provided DBT/distress tolerance skills|provided DBT/interpersonal effectiveness skills|provided CBT approaches|provided psychoeducation on improvement of sleeping habits|created a behavioral activation list with client|explored trauma and impacts on client's life|explored patterns of conflict|explored potential reasons for behaviors/symptoms|identified and processed issues around grief/loss|identified triggers|identified alternative behaviors/coping skills that have helped in the past|identified and explored strengths and/or support system|utilized person-centered modalities|utilized EFT modalities|utilized ACT modalities|utilized motivational interviewing (MI) approaches"]. [textarea name="17x" default=" " rows="2"]

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ADDITIONAL NOTS / ASSESSMENT
Medical Necessity: [checkbox name="medical necessity" value="Rapport building | Frequency History of Trauma | Client Crisis/Acute Issues | Time Necessary to address and contain intense emotional content |  Preventative measures to avoid higher level of care | Necessary for the therapeutic intervention utilized in session |  Addressing new or re-emerging symptoms | Limited healthy support network | Client is unable to share content with others in support system due to nature of topic | EMDR Protocol being utilized | Bi-weekly Sessions | Monthly sessions to maintain acquired skills | Symptoms are impacting multiple domains of life (relationships, work, school, 
community) | IFS protocol being utilized | Assessment and stabilization | Significant trauma history necessitates additional time for disclosure and containment | Address complicated issues related to diagnosis and clinical presentation | Grounding needed for symptoms that emerged during session | Reviewed homework | Client requested longer session time due to decreased frequency of sessions |  Prevent escalation to intensive level of care | Exposure therapy for post-traumatic stress disorder, panic disorder, obsessive 
compulsive disorder or specific phobia | Unexpected complication resulting from pharmacotherapy | Parental involvement 
 | Building a Healthy Support Network | BPD diagnosis requiring DBT sessions | Clinical symptoms impacting functional impairment causing client the inability to 
complete activities of daily living, occupational and/or social functioning|other"] [textarea name="variable_1" default="enter text here"]





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PLAN
Therapist will [checkbox name="cb14" value="meet with client in 1 week to assess mood/functioning, and implementation of treatment plan goal(s)|meet with client in 2 weeks to assess mood/functioning, and implementation of treatment plan goal(s)    meet with client in 1-2 weeks to assess mood/functioning, and implementation of treatment plan goal(s)|meet with client in 3 weeks to assess mood/functioning, and implementation of treatment plan goal(s)|meet with client in 1 month to assess mood/functioning, and determine need for continued treatment or termination|begin termination process with client|client will contact therapist to schedule next session.|Therapist will contact client to schedule next session."]. [textarea name="plan" default=" " rows="2"] [var name="firstname"] agreed to this plan.

MEDICATION
Client denies current prescription of medication(s). Client reports no changes to prescribed medication(s). Client reports changes to prescribed medication(s). Therapist and clt did not discuss medication. Will continue to explore medication changes in future sessions Client notes

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SYMPTOMS AND SUBJECTIVE
Client reports doing okay better than last meeting worse compared to last meeting not so good.

Session Note(i.e. what happened in session, additional details on interventions used, client response, plan for next session)
Client reported

firstname reports experiencing symptoms and/or has complaints about anxiety/worry depressed mood sadness loss of interest in pleasurable activities tearful or crying spells fatigue/low energy difficulty sleeping trouble falling asleep appetite changes difficulty concentrating low motivation poor academic/work performance isolation from others loneliness low self-esteem anxiety of social situations concerns of negative evaluation by others fear of embarrassing self panic intense fear/intense discomfort worry about having future panic symptoms/attacks muscle tension difficulty controlling worry/excessive worrying worry about job responsibilities worry about health worry about finances panic attacks fear hopelessness impulsivity hypervigilance grief worry about future of relationship low self-confidence interpersonal conflicts irritability emotional instability Binging/purging life transitions role confusion guild/shame grief OCD symptoms or behaviors lack of self care poor impulse control physical pain intrusive thoughts inability to make decisions poor concentration restlessness trauma other.

firstname discusses symptom management management of depression symptoms management of anxiety symptoms self-esteem ADHD friendships childhood/family of origin emotion dysregulation anger issues distress intolerance an adjustment to a stressor(s) grief/loss relationship distress relationship dissatisfaction relationship argument or regrettable incident with partner relationship intimacy concerns interpersonal ineffectiveness/conflict boundary setting a conflict with peers a conflict with family a conflict with coworker(s) self-care/hygiene issues sleeping issues physical activity/exercise substance use concerns alcohol use concerns cannabis use concerns nicotine use concerns trauma stressor(s)/coping mechanism(s) familial relationship distress employment issues financial issues legal issues housing issues parenting stress medical/health concerns medication concerns religious/spiritual concerns other.

.

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OBJECTIVE
Met with .

Encounter type: Individual Couples Family Extended Session Crisis Session Collateral without client present individual with collateral

Major Themes
Identity/Role Confusion conflict in relationship work/school problems stressors/coping methods childhood/family of origin traumatic events substance use goals/treatment planning grief processing conflict with peer group financial worries housing instability recovering from divorce/breakup new medical diagnosis cognitive impairment/functioning sleep issues biopsychosocial assessment other

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Therapist reviewed of homework discussion of progress towards goals provided psychological assessments assisted with boundary setting provided active and empathetic listening toward the client's thoughts and feelings engaged using open-ended questions stated normalization/validation of thoughts and feelings conducted therapeutic rapport building provided encouragement and reassurance reviewed family history/dynamics provided role-play exercises assisted client in problem-solving processed client's thoughts and feelings identified negative coping mechanisms provided psychoeducation about mindfulness and meditation provided relaxation skills provided psychoeducation identified and challenged cognitive distortions practiced cognitive restructuring reviewed self-care activities stated positive affirmations identified and/or reviewed positive coping skills reviewed and practiced effective communication skills and assertiveness techniques elicited change talk explored and reviewed effective parenting strategies processed the aftermath of an argument or incident explored patterns of closeness and distance in relationships explored couple's communication cycles observed and provided feedback on couple's communication and interactions provided DBT/emotion regulation skills provided DBT/distress tolerance skills provided DBT/interpersonal effectiveness skills provided CBT approaches provided psychoeducation on improvement of sleeping habits created a behavioral activation list with client explored trauma and impacts on client's life explored patterns of conflict explored potential reasons for behaviors/symptoms identified and processed issues around grief/loss identified triggers identified alternative behaviors/coping skills that have helped in the past identified and explored strengths and/or support system utilized person-centered modalities utilized EFT modalities utilized ACT modalities utilized motivational interviewing (MI) approaches.

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ADDITIONAL NOTS / ASSESSMENT
Medical Necessity: Rapport building Frequency History of Trauma Client Crisis/Acute Issues Time Necessary to address and contain intense emotional content Preventative measures to avoid higher level of care Necessary for the therapeutic intervention utilized in session Addressing new or re-emerging symptoms Limited healthy support network Client is unable to share content with others in support system due to nature of topic EMDR Protocol being utilized Bi-weekly Sessions Monthly sessions to maintain acquired skills Symptoms are impacting multiple domains of life (relationships, work, school,
community) IFS protocol being utilized Assessment and stabilization Significant trauma history necessitates additional time for disclosure and containment Address complicated issues related to diagnosis and clinical presentation Grounding needed for symptoms that emerged during session Reviewed homework Client requested longer session time due to decreased frequency of sessions Prevent escalation to intensive level of care Exposure therapy for post-traumatic stress disorder, panic disorder, obsessive
compulsive disorder or specific phobia Unexpected complication resulting from pharmacotherapy Parental involvement
Building a Healthy Support Network BPD diagnosis requiring DBT sessions Clinical symptoms impacting functional impairment causing client the inability to
complete activities of daily living, occupational and/or social functioning other

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PLAN
Therapist will meet with client in 1 week to assess mood/functioning, and implementation of treatment plan goal(s) meet with client in 2 weeks to assess mood/functioning, and implementation of treatment plan goal(s) meet with client in 1-2 weeks to assess mood/functioning, and implementation of treatment plan goal(s) meet with client in 3 weeks to assess mood/functioning, and implementation of treatment plan goal(s) meet with client in 1 month to assess mood/functioning, and determine need for continued treatment or termination begin termination process with client client will contact therapist to schedule next session. Therapist will contact client to schedule next session..

firstname agreed to this plan.