Topic 5 DQ 1 RESPONSE 2

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Arizona State University *

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42845

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Psychology

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May 31, 2024

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docx

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Uploaded by PresidentDragonflyPerson984

Topic 5 DQ 1 (Obj. 5.1 and 5.2) RESPONSE 2 In Topic 4, you created a treatment plan for Lucy. Create a SOAP note that would go in the client’s chart following the visit. Post the SOAP note as a reply to this discussion thread. For follow-up discussion, evaluate at least two of your peers' SOAP notes. Would you have documented anything differently? Why or why not? A SOAP note is an acronym for Subjective, Objective, Assessment, and Plan when it comes to documenting a client’s continuum of care (Cameron & Turtle-Song, 2002). As the Treatment Plan document was utilized for the second set of case notes, it is inferred that this was the second session with the client. Based on the imagined response in the Treatment Plan, I would note the following updated important information in a SOAP note format for the client's chart: Subjective: Client is suicidal. Client admitted she attempted to die by suicide stating, "I just couldn't take it anymore. Everything is too hard." Lucy's roommate found her unconscious in her dorm room with an empty wine bottle & Tylenol PM by bedside. Roommate reported Lucy was very upset the day before due to a C grade in two main engineering courses. Roommate reported that Lucy skipped tutoring and got drunk at bar, ignoring calls from parents all evening. Roommate came home at 1AM to see Lucy visibly upset still drinking wine in bed. Lucy is adamant about not wanting parents to know, and also does not know if she can return to classes in the Spring. Objective: Campus police call to therapist confirms Lucy was found unresponsive in dorm room the morning of roommate's call. Lucy called to cancel counseling appt. for the next day. Lucy is allowed back on campus with conditions of: tutoring 2x/week (less), counseling 2x/week, and alcohol education 1x/week for the rest of semester. Assessment: Clinical impression from subjective and objective notes in second session continues to support Severe Alcohol Use Disorder [F10.20] and Current Suicidal Behavior [T14.91A] due to only undergoing two sessions of individual counseling. Progress on principal diagnosis and treatment will be checked in one month.

Plan: Client should engage in a suggested 1x/week individual counseling and 1x/week school counseling in order to address principal diagnosis of discontinuing alcohol abuse and potential educational path changes or break from education to focus on mental health stability and rebuilding. References: Cameron, S., & Turtle-Song, I. (2002). Learning to Write Case notes Using the SOAP Format. Journal of Counseling & Development , 80 (3), 286. https://doi-org.lopes.idm.oclc.org/10.1002/j.1556- 6678.2002.tb00193.x

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