Clinical Note Taking for Therapists



guys thanks for tuning in my name is Lauren and you're watching social work scrapbook if you're new this channel is for new and aspiring social workers so I think you're in the perfect place and today I'm talking about clinical note-taking throughout the video I'll give you a brief hypothetical scenario an essential of how each note would be written note-taking is very very important and I think sometimes we tend to it we can get locked into kind of a free-form note-taking where you're jotting down what's happening but there really isn't any structure to their note that can throw a wrench in to how much it getting done and it can almost make you feel stuck so today I'm going to describe four of the most common ways to take a clinical note I'm gonna start with my most preferred method and that's called the v– soap note to walk you through a soap note the S stands for subjective so you basically write a sentence on what the client reports in session so for mine I put reports suicidal ideation period you can also provide personal history or any other information you've gathered there the O is going to stand for objective this are factual things that you saw in session and so what I saw were scratches and cuts visible on the wrist the a is your clinical assessment so a stands for assessment and you basically put together your subjective and objective and then you come up with what you think is really happening so client is at risk of suicide and then P is your plan the next method is very similar to the soap note method and it's commonly referred to as the Death Note dab stands for data assessment / response and plan so data in this format is going to include both subjective and objective they're both crammed in there under my data and then my assessment / response is going to include my clinical impressions so what I believe is happening and then the last letter is P stands for plan so this is what you plan on doing or any revisions you've made to your original treatment plan the basic said note is a little lengthy but it is very true to social work so you start with the behavior and whatever you see your client doing or not doing a is gonna be their effect or their mood S is gonna be any sensation so this includes the five senses and any stimuli in that respect is your imagery any fantasies flashbacks see is gonna be their self-talk or their personal narrative s is going to be their spiritual or religious state and whether you know that has any impact on what's going on in the session I is going to be interpersonal their level of social skills and then D is the drug or biological which is very helpful information to have the most recent type of note format is the Gilman HIPAA progress note using the same example the Gilman hep buzz closest to a free-form note that I've found you do need to record your start and end time of your session that begins your note and then your treatment modality is also at the top of your notes so I use solution based approach with this same client and then you want to show what you're seeing in the session as long as well as their functional status so how well they're adjusting or coping with their issues at hand any possible diagnosis and then your follow-up plan so those were the four common types of clinical note-taking and a way to structure them you will slowly find which one you prefer best each note is organized and certain way that helps you to see the client progression they give you a really great snapshot of each session so that when you're kind of feeling stuck you can look back through these little snapshots and see what's been working maybe what's not been working and then where you can go from there but if these four common types of clinical note-taking doesn't seem to fit or you just feel it's not right it's not something that I'm comfortable with by all means stick with your freeform note-taking you can watch my next video which is going to be on how to structure your own freeform note so that you're not missing any pieces in your own snapshot of your sessions with your clients stay tuned for that video thank you for being social workers and thanks for watching see you soon

12 comments

  1. Do you keep your clinical notes for each client in the same notebook or do you have a notebook for each one?

  2. These are very helpful ways to take notes. I was wondering, do you take notes in the freeform way first during the session. Then, do you organize it after the session in one of the other formats, such as SOAP? Thank you!

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