SOAP Method
In the SOAP format, which section captures the client’s feelings, concerns, and how they experience their situation in their own words?
What is the Subjective (S) section.
What do well-documented case files provide for the counsellor in the case that questions arise surrounding that counsellor’s actions in legal or ethical hearings?
What is protection.
What are case notes meant to create over time regarding a client’s counselling?
What is a track record of treatment and progress (or lack of progress).
Which process do counsellors need to have documented in their case notes that makes the client aware of their rights?
What is informed consent.
What three qualities should counselling records have to support good decision-making and quality care?
What are timely, accurate, and comprehensive records.
The SOAP acronym used in clinical case notes stands for four key documentation components. What are they?
What are Subjective, Objective, Assessment, and Plan.
Potentially suicidal clients, clients with homicidal intent, HIV positive clients with multiple partners, and cases of suspected abuse can be defined as what, according to Wheeler and Bertram (2019)?
What are high-risk cases.
What type of information in case notes includes only what the counsellor directly observed or what the client literally said and can be verified?
What is objective information.
Under which required circumstances can a counsellor break confidentiality? (Provide 1 example)
What is danger to self or others, legally mandated court testimony, suspected child abuse.
What must counselors and organizations follow in order to avoid risk during litigation or ethical allegations?
What is compliance with the organization’s written policies on record keeping and confidentiality.
Which part of the SOAP format is most likely to be reviewed by outside parties such as courts, auditors, or other clinicians, making clinical justification especially important?
What is the Assessment (A) section.
Why is it important to consult your supervisor for any potential high-risk situations? (Hint: 2 parts, regarding others and self)
What is supervisor liability and risking job security
What should counsellors do with client quotations in case notes to avoid accuracy concerns?
What is keeping quotations to a minimum and only including key phrases or critical statements.
Because client records can become public records, what information should counsellors not include in their case notes unless that information has a direct bearing on the client’s treatment?
What is identifying information about third parties (ex. family members, alleged extramarital lovers, or illegal acts)
What should counsellors assume will happen to the counselling record, meaning it should always be written clearly and professionally?
What is that the record may be subpoenaed and reviewed by others (e.g., court or boards).
The final section of the SOAP format is the treatment plan, and any plan should include what two types of goals?
What are short-term and long-term goals.
Name 3 "clearly understood parameters of adequate documentation".
What is client identification, previous treatment, informed consent document, financial arrangements, clinical assessment and/or DSM-5TR diagnosis, release of information, collateral information, treatment plan, case notes, academic standing/grades
What important changes should be documented if a client seems disoriented or shows an abrupt shift in functioning during session?
What are behavioural or mental status changes (e.g., confusion about time/place/person).
Give an example of when counselling records sometimes become legal documents in court cases.
What is/are custody battles, malpractice litigation, workers’ compensation, probation hearings, charges of abuse, involuntary commitments to psychiatric hospitals, etc.
What right do clients have regarding their counselling record that counsellors must always keep in mind when writing notes?
What is the legal right to review and request copies of their records/case notes (and have them sent to third parties with authorization).
The SOAP format is recommended because it brings what two qualities to counseling case notes that would otherwise be subjective and inconsistent?
What are consistency and continuity.
From a risk management standpoint, which step of documentation involves documenting what the client did or said that suggested they were considering engaging in or were actively engaging in high-risk activity.
What is the first step.
What is the documentation problem with writing “The client seems to be a drug addict” when you don’t have direct evidence, and what should be written instead?
What is that it is subjective and potentially harmful/libelous; it should be replaced with objective, verifiable facts (e.g., client admission, screenings, assessments, observed behaviours, or documented treatment focus).
Considering legal implications, with what understanding should a counsellor prepare each case record?
What is understanding that the case could proceed to court.
If a third party subpoenas case notes, what should a counsellor not do, and what should they do instead to protect confidentiality?
What is not sending documents immediately; instead consult an attorney/follow legal procedure to respond appropriately and protect privacy.