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Communicating Via Documentation

To continue on from Part 7: I’ve noticed that many counselors, even experienced ones, struggle to make effective use of the SOAP or DAP format required by their employers. I wanted to take a few moments to clarify things.

The SOAP note was initially used by physicians in the medical record, to make brief but helpful updates on patient progress from office visit to office visit. In its original form, the note worked something like this:

Subjective: This was ordinarily a complaint reported by the patient. As in ‘my back hurts’, or ‘I can’t sleep’, or ‘I fell and hurt my knee.’

Objective: Something the doctor did to measure or observe what was wrong with the patient. Take vital signs, for instance, or examine a wound, or check lab results. In physical medicine, this is according to established procedures, often with an eye to confirming a diagnosis.

Assessment: The physician’s opinion about the patient’s problem– its possible cause, or likely outcome– based on the subjective and objective data.

Plan: What the doctor intended to do (if anything) to remedy the problem.

This sounds like a fairly straightforward process, but things get a lot more complicated when you’re dealing with complex problems, particularly of the sort found in behavioral health clinics. It’s sometimes difficult to compartmentalize things into the discrete components required by this format.

One solution is to select one or two aspects of particular importance and focus on those. Another is to look at more aspects but provide less specific information about each.

Two examples: client Bob, who has until recently been dependent on illicit drugs, proclaims during group that that he’s drug-free when in fact you have sitting on your desk a report from a random drug test suggesting he hasn’t been. Here’s one way to document that.

S: “I’m proud to say I’ve been completely drug-free for a whole month, the first time for me in two years.”

O: Client’s random test on 6-10-15 came back positive for cocaine and marijuana.

A: Conflicting report from lab casts doubt on client self-report, as well as progress.

P: Meet with client individually in regularly scheduled appointment tomorrow. Discuss lab results and seek resolution. If client acknowledges use, explore further circumstances and evaluate status. If client continues to claim abstinence, explore possible motivational issues. Base plan on outcome of discussion.

But, suppose the session addresses some other areas of importance, and you want to cover those as well in the same note. You might try something like this.

S: Client reports he’s been drug-free for past month. Expressed much worry in group about divorce. Asked about whether insurance will cover sessions.

O: Recent random test positive for drugs. Business office left note in chart that insurance approved 12 more OP sessions.

A: Divorce proceedings in early stages, no immediate threat to treatment. Reimbursement has been assured. Needs to focus on lapse prevention, based on recent drug test results.

P: Meet tomorrow in individual session. Provide info about insurance. Discuss drug test results and interpret findings. Goal is to mutually developed plan to safeguard against future lapses, possibly through increased monitoring if client consents.

Seem logical? The best way we’ve found to teach clarity in documentation (and that’s really the goal) is to use real-life examples and ask the group for feedback on the quality of each student’s progress note. Is it clear? Easy to follow? Thorough, in the sense that it addresses all the necessary elements without unnecessary complication?

It takes a little practice, but it’s worth the effort. And it’s like riding a bike.