Case Notes
Student Name
University

Case Notes

Soap Case Note:

Client Description:

Client is a 52 year old, divorced African-American female with 2 children. Client has a 13 year old son and a daughter who is an adult. Client is dressed appropriate and is well groomed.

8/8/13 (S) Client reports have a lot of difficulty understanding her 13-year-old son. She stated her son “holds on to anger and can lash out at the drop of the hand”. She reports the last episode occurred when her son was outside, playing with some friends and one of the boys said something to him. She does not know what was said but her son just exploded. Client stated she is “concerns because she does not want anyone to hurt him and he gets angry over the least a little bit of thing that someone says to him”. As a result client reports arguing with her son and they both end up anger at one another. She is an older parent, and she reports have a little patience with her son.
(O) Client is a little frustration in reference to her son angry issues. In the beginning of the counseling session the client appears frustrated when she discusses some examples of her disagreement with her son about his anger and temper issues. Towards the end of the session the client was smiling and able to identify a better way to talk to her son by using different approach without being so angry. (A) Client feels hurt and anger because she is unable to communicate with her son when he gets anger. Client reports she unable find the right words to communicate with her son. Counselor and client were able to do a small role play during the session. This gave the client a chance to image the counselor as her son and the client was able to express her emotions and feelings when her son does not want to communicate right away. In addition she was able to look at the situation from her son perspective. The client repeated express being anger during the session and feels her son should open up immediately but she is still trying to grow longer patients with her son. After the role play the client was able to understand, she is forcing her son to talk right then and there. She is able to identify she is adding more fuel to the argument causing her son to shout down.
(P) Counselor will work with the client in a week to follow up on the new approach she will used with her son during an argument, if an argument has taken place during that time. Counselor will plan to work with the client to further discuss client feelings she is harboring about her relationship with her son. Counselor will also conduct role play to further assess client emotions and feelings. DAP Case Note: 8/8/13 (D) Counselor met with client for a 20:14 min counseling session. Client reports have a lot of difficulty understanding her 13-year-old son. She stated “her son holds on to anger and can lash out at the drop of the hand”. She is concerns because she does not want anyone to hurt him and he gets angry over the least a little bit of thing that someone says to him. As a result client reports arguing with her son and they both end up anger at one another. She is an older parent, and she reports have a little patience with her son. The rest of the session focused on her views of how she can communicate with her son. During the session the counselor and client were able to do a small role play. This gave the client a chance to image the counselor as her son and the client was able to express her emotions and feelings when her son and her are arguing. The client repeated express being anger during the session and feels her son should open up immediately. (A) Client is frustrated and anger because she is unable to communicate with her son when he gets anger. Client is willing to continue further counseling session to address her frustration and anger. In addition she is also willing to try role play exercise to help with better communicate with her son (P) Next session scheduled for 8/16/13 at 4pm. Continue work on the new approach she will used with her son during an argument, if an argument has taken place during that time. Further discuss client feelings she is harboring about her relationship with her son. Conduct role play to further assess client emotions and feelings.

According to Mears (2010) case conceptualization is a way that counselors make sense out of the information they have gathered during a counseling session (pg. 282). Case conceptualization involves information from the assessment and leads to a diagnosis and effective treatment planning (pg. 282-283).In this week media Counseling competencies—the application of ethical guidelines and laws to record keeping. Dr. Patton discussed with the panel his primary reason why is so important to have the client case note in place. He stated in case a client has to be admitted into the hospital or needed some other kind of level of care; he wants whoever is taking on a client’s case to have a good idea of what is going on with the client. He stated that “everything he puts in his notes is always about client stated, or my client noted” (Laureate Education, 2010b).
According to ACA Code of Ethics (2005) Standard A.2.b. Types of Information Needed states “counselors explicitly explain to clients the nature of all services provided. They inform clients about issues such as, but not limited to, the following: the purposes, goals, techniques, procedures, limitations, potential risks, and benefits of services” (pg.4). Dr. Patton mention in the media that it is important to inform the client that he is going to be making notes about their session, that there will be a record of their work. He stated it is a part of the disclosure statement (Laureate Education, 2010b). According to Prieto& Scheel (2002) case documentation and record keeping can be used as a useful process in supervisor. One strength using SOAP notes is it provides an adequate amount of information, the format is simple and well-organized if you follow the steps. Dr. Reicherzer stated she wants to write her notes in a way that people will understand and writing things in “the clearest way possible is important so other can read her case notes”. She also stated using SOAP formula or DAP formula, is important to be formulaic (Laureate Education, 2010b). Some limitations using SOAP notes is the shortness of this format may prevent using it to assess progress, and the need to record precise information (Delitto and Snyder-Mackler, 1995). In addition Delitto and Snyder-Mackler (1995) believe “the “subjective” component of the SOAP formant is lacking adequate measurement characteristics on which to base diagnostic decisions” (pg. 206). One strength using DAP notes is it seem to be shorter than SOAP. The assessment and plan section is shorter straight to the point. One limitation is that it not detailed enough. In conclusion documentation is vital in counseling process it helps counselors communicate effectively and have a record of keeping information documented and monitoring client progress.

References

Delitto, A. & Snyder-Mackler, L. (1995). The diagnostic process: examples in orthopedic physical therapy. Physical therapy, 75:203-211. Retrieved from http://ptjournal.apta.org/content/75/3/203.full.pdf+html

Laureate Education, Inc. (Executive Producer). (2010b).Counseling competencies—the application of ethical guidelines and laws to record keeping. Baltimore, MD: Author.
Mears, G. (2010) Assessment, Case Conceptualization, Diagnosis, and treatment Planning. In B. T. Erford (Ed). Orientation to the counseling profession: Advocacy, ethics, and essential professional foundations, 269-297. Upper Saddle River, NJ Pearson Education.

Prieto, L. R., & Scheel, K. R. (2002). Usingcasedocumentation to strengthen counselor trainees' case conceptualization skills. Journal of Counseling & Development, 80(1), 11.
Retrieved from the Walden Library databases.