Which Section?
Client arrived with her mother and frequently looked to her before answering questions.
A client under the age of 18
What is a minor client?
Using direct client quotes in SOAP notes is a good idea.
What is true?
A client who states she has an appointment scheduled for the surgical procedure next week
What is an AO client?
S: Client presents for PT(+). Cl has no previous history, and no significant medical issues. Client has no doctor and was not on birth control. Client took HT(+) and is excited to be pregnant.
No need to document negatives or checklist-style medical background statements that are not directly relevant. No strengths listed.
Client is AV due to previous abortion and being upset about being pregnant.
What is Assessment?
A client who speaks French
What is "a non-English speaker"?
If spirituality is discussed, it should be documented that this was client-initiated.
What is true? Anytime faith is discussed, it should be clear this was a client-initiated conversation.
A client who was not planning a pregnancy but excited about possibility and has been with FOB for 4 years
What is a parenting client?
Plan: Client declined follow up scan due to wanting to proceed with abortion.
Needs to be documented that client was given Your Decision brochure or if client declined it.
Client scheduled follow up ultrasound for next Tuesday and received Your Decision, PNVs, and nausea aids.
What is Plan?
A client who is currently addicted to heroin
What is "special needs"?
SOAP notes should capture everything discussed in session.
What is false? SOAP notes needs to document only the most relevant information needed.
An 18 year old client who is still living with her parents and is in a "situationship" with FOB. Cl states she told FOB and he ghosted her, but states she plans to parent. Parents are supportive of her continuing the pregnancy.
What is an at-risk client?
Observations: Client seems immature and dressed inappropriately.
This information is subjective, not objective. Language should remain neutral.
Client states that she plans to go back to school to get her nursing degree. Counselor affirmed cl on her desire to help others and her hard work ethic.
What is Strengths and Situational overview?
A client who believes she was coming to Planned Parenthood
What is a "wrong door" client?
You should always list cl's symptoms of pregnancy in your SOAP notes.
What is false? (Symptoms of pregnancy is included in the case, it does not need to be duplicated in the SOAP notes unless it is pertinent to understanding her feelings about this pregnancy (such as excessive nausea leading her to being AO))
A client who states she had a previous abortion and it was very traumatic. Cl is leaning towards parenting.
What is an AO client?
Assessment: Client is AO, has already ordered the abortion pills.
Need to state the reason why client is AO.
Client teared up when hearing abortion procedures.
What is Observations?
A client who states she was blacked out during the time of conception
What is "a pregnancy the result of rape/sexual assault" flag?
Past abortions should be included in critical notes.
What is false? Critical notes are used when information must be known by anyone opening the file immediately.
A 17 year old client who was planning pregnancy with FOB, has already told both her parents and his parents, everyone is excited and supportive
What is an AV client?
Critical notes: Client has had a previous abortion at 13w
Critical notes should not document previous abortions. Instead, if you want to convey that client should be allowed later scans, you would write "Bonding scans okayed into the 3rd trimester."