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ElderClover9632
Writing case notes is a major element of being a mental health…
Writing case notes is a major element of being a mental health provider. Everything you do will be documented in the client’s chart, and it is important to practice organizing client data and writing SOAP notes.
SOAP note related to the Alejandro case:
Alejandro is a 12-year-old Mexican boy who lives with his father and younger brother. About a week ago, his mother passed away. His teacher, Mr. Kombs, reported that he went from a fun-loving boy to a boy with “sad eyes.” Mr. Kombs also reported that Alejandro falls asleep in class, has a hard time focusing, and doesn’t speak much. He tends to stare into space and doesn’t go outside to recess at the appointed time. He has asked Alejandro a few times if he is OK, and Alejandro shrugs his shoulders. For the last two days, he has been tearful in class out of nowhere and asked to go to the restroom. Unfortunately, the teacher doesn’t know how the mother passed. He has reached out to Alejandro’s father, who has not returned any phone calls.
Instructions Part 1: Review the Alejandro case, and then complete the interactive SOAP Note Form to accurately summarize the case. The sections of the form you will need to complete include: Client name (Alejandro). Subjective. Objective. Assessment. Plan (be sure that your plan is specific and measurable).
SOAP NOTE FORM:
Client: Alejandro
Date of Session: 03/10/23
Subjective: The patient reported that he feels disconnected from his wife since getting separated. He reportedly wants to have a strong co-parenting relationship with her, but he believes that she is still too mad at him for his infidelity to be civil. He discussed how hard it is to have no communication with her. He also expressed feeling worried each time they have a planned drop-off and pick-up that she will yell at him in front of their children. He indicated that he wants to be honest with his teens about his mistake, but he wants to tell them in his own way. According to the patient, he is sure that his son will no longer want to visit him if he knows about the infidelity because he is very close to his mother.
Objective: The client was on time; oriented to person, place, and time; and well-groomed for this session. He was anxious as evidenced by his bouncing foot and hand wringing. His affect was flat, and his mood was anxious and stressed. He has been separated from his wife for the last six months, and they have an informal agreement about who gets their two teenagers each week.
Assessment: F43.22 Adjustment Disorder with anxiety The client appears to be very concerned about the relationship with his children being affected by his separation. No suicidal/homicidal ideation or plan. He is making moderate progress in his effort to adjust to life as a single parent. Plan: Continue individual therapy to explore his fears and concerns about the impact of his separation on his children. Refer to divorce mediation. Start weekly BAI assessments.
Therapist: Sandy Counselor
Part 2: Consider that you are a psychology intern working at an outpatient mental health center. There are three interns at the center, including you, and Alejandro is your client. You are really struggling to get him to open up to you. discuss the importance of consulting with your colleagues about your cases. What are the risks and benefits to consultation, and what is your plan to avoid the risks?
