Case Study Documentation

Case Study Documentation

For this discussion, select a case study you have not already chosen. Develop a summary of a counseling session that you might have with this client.

Then, use the SOAP Note Form multimedia piece linked in the Resources to create the necessary clinical documentation to represent the summarized counseling session. Title and upload your SOAP note:

Title (example: "Ima Learner-u10d1-Soap Note XYZ Case Study").

Response Guidelines

Read the posts of other learners and respond to at least two. In each response, evaluate the clinical documentation of your peer. Determine if all the necessary information is in the documentation and, if not, propose how to include the information. Use citations from your readings and research to support your evaluations and questions.

Learner 1:

Chosen Case Study: Collin

For the current study, this learner chose a case study that has not already been chosen throughout the remainder of this course. Collin is a 20-year-old black, gay male who presents as actively using methamphetamine (Capella, n.d.). Collin declines any current withdrawal symptoms, but notes that he is uncertain if he is able to stop use which causes him fear (Capella, n.d.). Collin further indicated precipitating factors of use as meth makes him “feel good”, concurrent lacking social support related to his sexuality and fears of coming out, as well as potential symptoms of daily sadness and anxiety related to his sexuality (Capella, n.d.).

Hypothetical Counseling Session Summary

The presented hypothetical counseling session summary describes Collin’s fifth counseling session, following Collin’s disclosure of his sexuality to his mother and following detox from methamphetamines. During this session, Collin presented with a sense of restlessness, as evidenced by constant fidgeting, bouncing of the leg, scratching at his wrist every few minutes, and client’s description of “my mind keeps racing and playing out the what if”. Collin reported that he and his mother’s relationship has been more transparent as a result of his coming out and his mother being empathetic and sharing tears over this expression. However, at this time, Collin has identified urges to inject methamphetamine and indicated worry of “now I have to tell my dad”.

SOAP Note

The active SOAP note for this case study is attached below.

Subjective (S)

The subjective section of a SOAP note includes direct individualized statements from the client, what others report directly about the client, client narrative of his world experience, or reported feelings, concerns, or comments made by or about the client (Hodges, 2016). Within the current case study, the subjective section example is as follows.

Objective (O)

This section within the case note contains factual information, clinician observations, measurable assessment results, and documentation presented from other providers (Hodges, 2016).

Assessment (A)

Assessment includes the section within the case note that summarizes counselor conceptualization of the client’s current diagnosis, including clinical impressions and DSM-5 prognosis (Hodges, 2016)..

Plan (P)

This section within the case note describes current treatment parameters, action plan, interventions used, active treatment progress, and date of next appointment and anticipated progress for interventions planned (Hodges, 2016). Within the active case study, the current plan section of this case note includes as follows.

References

American Psychiatric Association (APA). (2023). Diagnostic and statistical manual of mental disorders (5^th edition).

Capella University. (n.d.). Addiction case study. Retrieved from https://media.capella.edu/CourseMedia/COUN5261/ACS_Treatment/wrapper.asp?sso=true

Hodges, S. (2016). The counseling practicum and internship manual: A resource for graduate counseling students (2^nd edition). Springer.

National Institute of Drug Abuse (NIDA). (2023). Screening and assessment tools chart. Retrieved from https://nida.nih.gov/nidamed-medical-health-professionals/screening-tools-resources/chart-screening-tools

• Personal Reflection Notes Chapter 3
• Annie's Anxiety-Navigating Models, Assessments, and Systemic Perspectives for Understanding
• Discussion 2
• Self Assessment Journal Entry
• Case Scenario Eve
• Fostering Communication and Empathy
• Letter to Addiction Facility Director
• Self-Care for Families Struggling with Addiction Introduction
• Perspective on Self-care
• Interventions