Create a 1,000-1,250-word scenario where you believe a client needs to be assessed for a RISK assessment/ for AIDiction Counseling
Writing SOAP and DAP Notes Resource
Writing SOAP Notes
â€¢ Always write the S, O, A and P in capital letters at the beginning of each section and circle it.
o (S) This is the subjective part of the progress note as it is always client statements or what the client reports.
o (O) This part of the progress note is the objective view of what the counselor observes.
o (A) This part of the progress note is a clear statement of the counselor’s assessment of the client. What is the client’s (Ct.) overall function? Mental status? Has the client made progress? If you are using the Beck Depression Inventory, the score would go here.
o (P) What is the plan for the next session? This should be consistent with your treatment plan.
â€¢ Example: Begin by writing a capital (S), then circle it.
o (S) Ct. reports he attended 4 A.A. meetings this week. Ct. stated, I am beginning to feel less depressed.
o (O) Ct. was on time for his appointment. Ct. clothing was neat and clean. Ct. was cooperative during the appointment.
o (A) What is your assessment of the clients affect, mental status, and functioning? Ct.
appeared happy with his success at going to AA and having 23 days of sobriety. Ct. affect was appropriate to content as he smiled when reporting his successes. Speech was rapid, but not pressured.
o (P) Write a plan for the client’s future treatment. Do you need to update the treatment plan? For example: Ct. will continue with A.A.
meetings and find a sponsor by 12/12/2013. Ct. will begin group counseling on 12/9/2013.
Writing DAP Notes
o Refer to the (A) and (P) in the SOAP note examples given as they are the same.
o (D): Represents data. What are the counselor’s observations? Also include any statements made by the client here.