SOAP Note Best Practices
What does “Objective” mean in a SOAP note?
Observable, measurable data such as client actions, behaviors, and physical observations.
What is a key engagement strategy for working with clients with IDDs?
Using clear, simple language and visual aids to enhance understanding.
What is harm reduction?
A strategy that focuses on reducing the negative effects of substance use rather than demanding abstinence.
What is the main goal of trauma-informed care?
To create a safe and supportive environment that avoids re-traumatization.
What is one technique for engaging a withdrawn adolescent?
Building rapport through shared interests and allowing space for trust to develop.
What should the “Assessment” section of a SOAP note include?
Clinical interpretation of client progress, barriers, and response to interventions.
Why is routine important for clients with IDDs?
Predictability reduces anxiety and helps build confidence in daily activities.
Name a commonly used harm reduction technique.
Providing clean syringes, supervised consumption sites, or medication-assisted treatment (MAT).
What is the difference between trauma-informed care and trauma therapy?
Trauma-informed care applies to all service providers to ensure safety, while trauma therapy is a clinical intervention.
Why is it important to give children choices in decision-making?
It fosters autonomy, builds confidence, and reduces power struggles.
What are two common mistakes made in SOAP notes?
Writing subjective opinions instead of objective observations; omitting measurable progress indicators.
What is a common misconception about individuals with IDDs?
That they cannot learn or become independent; many can thrive with appropriate support.
What is one reason a client might relapse after progress in recovery?
Triggers such as stress, social pressure, or returning to environments associated with past substance use.
Name two common signs of trauma in a client.
Hypervigilance, emotional numbness, avoidance, or difficulty trusting others.
How can you modify communication for a client with limited verbal skills?
Use visual aids, body language, and alternative communication methods like picture exchange systems.
Rewrite this poor SOAP note statement "Client had a bad day."
Client verbalized frustration, stating, ‘I feel overwhelmed.’ Client was tearful and avoided eye contact.
How can you de-escalate a client with IDDs who is experiencing frustration?
Provide a calm, low-stimulus environment, use simple reassurance, and give choices to re-establish control.
What is motivational interviewing, and how does it help clients in recovery?
A client-centered technique that encourages individuals to explore their reasons for change and build self-motivation.
Why is consistency important when working with trauma-affected clients?
It builds trust by creating a predictable and stable environment.
A client refuses to engage in skill-building activities. What should you do?
A client refuses to engage in skill-building activities. What should you do?
In the “Plan” section of a SOAP note, what should always be included?
Next steps, follow-up tasks, referrals, and scheduled interventions.
What should you do if a client with IDDs is nonverbal and struggling to express needs?
Use alternative communication methods such as visual cue cards, sign language, or technology-based tools.
What is the best way to respond if a client discloses recent substance use?
Remain nonjudgmental, encourage reflection, and discuss next steps without shaming the client.
How can you respond to a client who suddenly shuts down or dissociates during a session?
Speak in a calm voice, offer grounding techniques, and allow space for the client to regain a sense of safety.
What is the best way to engage a client with a history of distrust toward authority figures?
Be consistent, transparent, and demonstrate reliability over time to build trust.