Question
Clinical Notes
Clinical
Documentation
This assignment
provides an opportunity to develop clinical documentation, specifically how to
use the SOAP (subjective, objective, assessment, and plan) note format. The
purpose of clinical documentation is to represent the client’s concerns and the
counselor’s observations in a holistic manner, which enables other
professionals to better understand what is happening in the client’s life.
Assignment
Instructions
Based on the Biopsychosocial Assessment and Treatment Plan, develop two case notes that provide the necessary clinical documentation. Prepare the notes as if you conducted these sessions with the client. Utilize the SOAP note format to create two separate notes
1. The first note represents the Biopsychosocial Assessment.
a.Evaluate the Biopsychosocial Assessment in order to create necessary clinical documentation.
2. The second note represents the Treatment
Evaluate the treatment plan in order to create necessary clinical documentation
Expert Solution
Subjective ;Sarah reported a willingness to
change their behavior and to stop opiate use. However, they expressed concerns
regarding their toxic environment and its impact on the change they are trying
to achieve as they stay with an abusive mother. Sarah reported that the primary
cause of her drug use is the sexual abuse by her mother's boyfriend. Despite
their low moods, the client appears to be well-oriented with personal time and
place.
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