Having difficulty with writing documentation (SOAP notes)

[andgelyo]

I will be taking this class over again next semester, and it includes documentation for fieldwork. I understand the general concept of SOAP, but i am greatly frustrated as when i do the worksheets and look at the answers in the back of the book, they are very different from mine. Am i the only one struggling with documentation? I feel like my classmates prior understood it pretty well, but for me, the material is coming to me very slowly. I have reread the entire book and have done all the practice worksheets and i still struggle with writing SOAP notes. It just doesn't "flow" correctly in my opinion. Anyone have any advice to become better at documenting? Any online resources? Feel free to post any tips, thanks in advance.

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[WinginIt]

You have a class dedicated specifically for SOAP notes?

At any rate, documentation is a part of OT life & work. Practically everything depends on it - reimbursement, especially, which once you're out in the real world, is what it's all about. They've drilled it in it over and over - if you didn't document it, it wasn't done. It will save your butt when you think it's just "another note" and the family or patient says this and you say that. At least you'd have it in writing.

What is you current understanding of the different parts? What are you struggling with?

 

[andgelyo]

Hello Winginit,

This may seem like a dumb question, but I'm having trouble differentiating between the different stages of SOAP notes( for example: is contact note the same as initial eval note?). Also here is a sample soap that I composed( if you have the Gately and Borcherding book, i based this off of Ryan on page 67).

SAMPLE SOAP NOTE
(Based on "Ryan" pg.67 of Borcherding and Gately)

S- Client reports that he has nothing to live for and doesn't have any friends. Client continued to say that his family would be better off without him, and that teachers at school hate him. Client verbalized suicidal ideation by stating "I should've done it right and used a gun!"

O- Client participated in 45 minute "self regulation" group session at partial care program to improve emotional regulation skills. Client appeared to be unkempt and wore a wrinkly dress shirt. Client was initially quiet and withdrawn from group, however when asked by the instructor "what relaxes you?" client immediately pulled out an old family picture and stated "it reminds me of better times". Client then yelled at another group member when the group member made fun of the picture. Client verbalized aggression by stating "You better watch yourself and watch how you talk to me!" before storming out of the room.

A- Client's unkempt appearance, verbal aggression, and inability to sit through and complete group session interferes with client's social participation and self regulating skills. Client's identification of an object that relaxes him indicates good potential to improve emotional regulation skills. Client would benefit from group sessions that address emotional self-regulation, and instruction in ADL activities that include personal hygiene and appearance.

P- Client to continue attending self-regulation group for 3x/week for 1 month to improve emotional self regulation. Client's behavior is to be critiqued by instructor and other group members, as well as have verbal feed back on appearance.

I just think that it's not as smooth as other soap notes based on the back of the book, as I am really trying to get an A in this class.

 

[133909]

Don't use quotes in any area except the "S". Also, where are the LTG and STG and tx plan in the "P"?