Clinical Writing, Goal Setting and Treatment Planning

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Clinical Writing, Goal Setting and Treatment
Planning
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Types of Documentation

• SOAP notes (subjective, objective, assessment,
  plan)
• DAP notes (data, assessment, plan)
• Phone calls with cx or collaterals
• Summary note
• Demographics
• Primary problem(s)/reason for referral
• Health concerns/treatment
• Major psychosocial stressors
• Important relevant relationships/supports
• Primary goal(s)
• Letters/reports to court or service providers

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Professional writing

• Use of language
• Descriptive
• Behavioral
• Distinguishes facts from hypotheses
• Brief and to the point.
• Watch Amanda, write a SOAP or DAP note, then
  discuss

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Example SOAP note

• S Cx states she doesnt see much chance for
  improving her life.
• O Cx initially did not acknowledge a problem
  with using and argued with writer later in the
  interview she appeared sad and hopeless that she
  can make positive changes.
• A Cx appears to be using and this is
  negatively impacting her school work and
  relationship with parents.
• P Writer will set up a meeting with parents
  and cx.

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Example DAP note

• D Cx was referred due to failing grade she
  initially denied using substances but later
  acknowledged that she is using and feels hopeless
  to change the situation.
• A Cx has relapsed and is not yet ready to
  commit to sobriety.
• P Writer will meet with cx and her parents to
  discuss limit setting at home and progress in
  school.

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What is a Treatment Plan?

• Intake/assessment results in an understanding of
  client needs.
• Problem list and corresponding goals are mutually
  agreed upon.
• Strategies to accomplish the goals are identified.

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Goal settingGoals should

• Be mutually agreed upon
• State what will be achieved
• Be within the clients reach
• Be measurable
• Include a target date for completion.

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Effective Treatment Plans

• Explore and problem solve barriers to goal
  achievement.
• Identify strategies logically linked to the goal.
• Include when strategies will be completed.
• Incorporate others as appropriate.