SOAP Note Purpose and Structure

Posted on October 10, 2021 by admin

Note: Post is published and still under development as of 20211010

Additional links to reference:

Free SOAP Notes Templates for Busy Healthcare Professionals

https://www.icanotes.com/2018/04/25/tips-for-writing-better-mental-health-soap-notes/

 

A SOAP (Subjective, Objective, Assessment, Progress/Plan) Note is a document used by a clinician (Licensed Clinical Social Worker or Associate Social Worker) while engaging with a client.  The outcome is a written record which can be used for maintaining an historical record, analyzing trends, efficacy of treatment/interventions, justification for escalation, and so forth.

Each clinician (Medical Doctor, Nurse, Social Worker) may have a different area of focus, detail and structure within their SOAP Notes.  For me (Social Worker), I’m going to start very simple, and customize as needed.  While I prefer paper to capture information, my plan is to create an electronic version of the SOAP Note in Microsoft Excel.  That way, I can search for keywords, etc.

This website gave a good overview for SOAP Notes for Social Workers.  Here is my interpretation of the four (4) key areas to observe and capture within each client interaction:

Subjective Data

Objectively, while withholding any judgment, recording (clinically important) statements made by client (person/s in front of me) during session.  The verbal statements are received as input and may include feelings, thoughts, actions, treatment objectives, concerns.  Typically, this would be something recent and top-of-mind, but also could be something from the past.  A good example is a client who says, “I had a good day”.  In this section, I’m not making meaning of the phrase, but it’s worthwhile to make note.

Objective Data

What I’m observing as a physical manifestation.  What I’m clinically measuring using a tool (FIT, Mini Mental-Health, etc).  In this section, I’m noting my observations, but I’m not making meaning of or interpreting it.  The physical observation can inform the verbal input.  For example, if the body language is tense with rapid breathing and red-faced, then that informs the verbal statement within the prior subjective section.  This section is classic grooming observations: clothing presentation; hair combed/brushed; shaven; general hygiene.  Observing items within the living space is important to note – carpet cleaned; hoarding; trash piles away from garbage can, etc.  In this section, I’m also observing “how” someone is relaying similar/identical information that they may have done in the past, noting the information is relayed with different intensity, for example.  If within the session I captured an assessment (FIT, Mini Health Status Exam), then I have the raw data and can interpret it within another section.

Assessment

Outcome of reviewing the above Subjective and Objective notes, where I’m synthesizing, assessing or understanding a through line or possible hypothesis of the data — making meaning of it all.  I can also be reflecting back on prior sessions and seeing patterns of change, ability for client recall, what’s working, what’s not working, etc.  Seeing how family dynamics over the course are impacting client progress, etc.

Progress and/or Plan

This is my opportunity to step back for a moment and see things at a higher level.  How is the client’s progress being evaluated.  Have the client’s symptoms changed – decreased increased, plateaued.  What specific changes has the client made.  What actions has the client completed that maybe a first.  What are the next actions regarding treatment (talk therapy, actions, meds, etc).

Additional items to include in a SOAP aka Progress Note

-What is the specific and tangible goal we’re heading to, so we have a point-of-reference when we arrive somewhere.

-Is there a RISK to self, to others, from others.  If that happens, what is the plan.

-Each session has a date, and a start and finish time. Everything is documented on the progress note, including any lateness or shortened sessions.

-What is the progress made towards a discharge plan

-What community support services does the client need and how to integrate this into treatment plan.

-What is the plan and scheduled day/time for next session.

-What’s getting in the way of client’s goals or progress – what are the stressors.

 

 

 

Posted in SOAP Notes, Social Worker | Leave a comment

Problems for veterans

Posted on October 3, 2021 by admin

A possible scenario:

Veteran is discharged from military service and finds themselves back in the United States.  Challenge could be one or more of the following:

  • Homeless with housing not affordable
  • Housed but soon to be homeless
  • Lease violations leading to eviction
  • Medical attention needed
  • Mental healthcare attention needed
  • Trauma: PTSD
  • Maturity affecting independent living
  • Co-dependency with other veterans (housed/homeless)
  • Substance abuse challenges
  • Relax and Stress Management
  • Dental/Vision attention needed
  • Physical Disability (TBI, missing limbs)
  • Other health problems
  • Income needed (possibly to get out of poverty) – find gainful employment
  • Financial Management assistance required
  • Legal problems
  • Case management/representation/advocacy needed/backlog

 

Note: Some of these ideas came from this website

Posted in HUD-VASH, Problem | Leave a comment

Registering as ASW with BBS

Posted on August 4, 2021 by admin

Desired Outcome:

Registering as an ASW (Associate Social Worker) with the BBS (Board of Behavioral Sciences) in California.  Note: The following applies for me, as I graduated from USC (University of Southern California) with a MSW (Master of Social Work) degree.  I also live and wish to work in California.

Why completing this registration is important?

Getting a job

I’ve found, in general, that being attractive to employers requires an ASW registration.  It means you can perform clinical work, under the supervision of a fully state-licensed mental healthcare worker.  The other reality, from perspective of an employer, is that an ASW can bill their services to insurance.

Continuous Learning

Between the ASW and the LCSW (Licensed Clinical Social Worker) are a series of courses that must be completed before sitting the final exam (ASWB, I think it’s called).  One course, which gets much attention, is Law and Ethics.  Even after the LCSW, it’s not over, as there are opportunities to do more learning and earn CEUs (Continuing Education Units).  The point is that the ASW continues where the MSW left off.

ASW leads to LCSW

There are different paths, and I’m on the path towards LCSW.  While my preference is Macro-focus, I recognize that having a LCSW is a solid foundation in understanding what is really happening on the frontlines.  Macro is much needed, but can also assume one really understands what’s happening before policy/programs can be created and integrated.

Private Practice autonomy

The LCSW can open doors to opening one’s own private practice.  My understanding is that most psychotherapists in the US are Social Workers.  Having a LCSW offers a lot of freedom and choice in one’s niche.  Of course, while being an ASW, you cannot have your own private practice — within the realm of ASW.  It’s OK for an ASW to work in a private practice headed by an LCSW.

Steps in the process:

Application (paper-based)

The Main Page for FAQ and forms for application for ASW.  I thought the form was very simple, short and clear.  Maybe what made it simple for me was that I didn’t have issues with last name, had graduated from a CA school, and live in CA.  The key is to fill out the form really accurately, and be consistent across all forms.  While I know the BBS are considering some automation of the process, they are currently wanting the paper form because of the “ink” signature.  Cost of Application: $150 (either check or money order).  Cost to mail: $7.65 to mail it with tracking and return signature.

Transcripts

The ASW registration requires transcripts from your school showing courses taken, grades, etc.  Because I still have access to the myUSC portal to USC, it was really easy to request the transcript.  The BBS have the option of the school sending electronically to an email address – that’s cheaper and faster.  While I could see my courses/grades online, the transcript still has to come directly from the school to (in this case) the BBS.  Cost: $12 for a PDF transcript.

Fingerprints (LiveScan)

Because we’re (theoretically) coming out of COVID-19, as of today – August 4, 2021 – I had some challenges finding a location that has LiveScan and can schedule.  My goal was to get the LiveScan appointment soon than later.  I could have sent the application first, waited for LiveScan, and then sent the results later.  But, my goal was to get everything done all at once.  Good thing is that Morro Bay Police Department had an opening today, so I got everything done today and mailed everything today to BBS.  LiveScan is the preference because the fingerprints are immediately sent to, in my case, Sacramento for background check processes.  I was told that, because I’ve done LiveScan before, that the turnaround maybe faster.  The agent said that it could take from 1 day to about a week to complete.  Note: Keep in mind the costs can vary by location and agency.  Cost: $84 ($49 plus $35).

Law and Ethics course and exam

When the ASW is registered and processed, then the first course is Law and Ethics.  This will be covered more in a different post, but here’s some general info:

  • If you graduate from a California school, and are registering with BBS in California, then (according to CSWE) the MSW program included the coursework for Law and Ethics, and you don’t have to do the course.  You can fast-track and just do the exam.
  • Must be taken within a year of registration
  • Must be taken (for each year you re-register) – not necessarily passed
  • But…  if you fail it, then you have to do some 12 hour course before taking it again.
  • After several years (in the 6th year, I think) you must pass it in order to get a new registration number – which carries over all your hours.
  • Bottom line: Pass it first time in first year.
  • I had purchased a course from the NASW on the topic.  I’ll be going through that in detail within different page/blogposts.
  • There are various programs (e.g. TDC) that are exam prep courses for ideally passing first time.  I’ve seen this cost around $265 for the course.

Summary

As of 20210804, now I wait.  The paperwork has been mailed; the fingerprints have been submitted, the transcripts have been emailed by now, and I’m just now short of a couple hundred dollars…

20211002 Update:  It took 30 days for the check to clear.  Day one is when check cleared (9/7/21).  Because of short staffing (COVID related) it can take up to 60 days to process.  That means it may be early November, 2021.  I’ve linked my email address with my BBS record, so I can review progress within CA Breeze.

 

 

 

Posted in ASW, Social Worker | Leave a comment

CA Gov Newsom calls for voluntary 15% reduction in water usage

Posted on July 9, 2021 by admin

X-Ref to article on July 8, 2021

Call is to consciously reduce water usage thru summer and possibly into the fall of 2021.  Bottom-line, we are back to drought conditions and reservoirs are running low.

Also, the excessive heat conditions recently in Pacific Northwest are now having an impact further south – California.

Closer to home – “…Lopez Lake, a reservoir in San Luis Obispo County formed by a dam on the Arroyo Grande Creek that is at 34% capacity.”

“California’s Mediterranean climate means it doesn’t get significant rain or snow until the winter. The state relies on snowmelt in the mountains to fill its reservoirs in the spring, which then provide water for farms, homes and fish throughout the year.”  I remember when living in Ojai (2007-2015), that our weather was a factor of colder temps and snow in the Sierra Nevada’s.  If that somehow doesn’t happen (snow, etc) then we end up with a shift in weather patterns towards California.  This is something to further investigate.

“The Democratic governor is asking for voluntary conservation efforts, such as taking shorter showers, running dishwashers only when they are full and reducing the frequency of watering lawns.”  I’ve always done the “Navy shower” method where you turn the water off during soaping up — I’ll continue that.  Probably also see if I can shower every other day if possible.

Of course, there will be groups that say we redirected water prematurely.  The only issue is — what do we do now?

Posted in Climate Change, Water in CA | Leave a comment

Issues Ramping up in Aviation Industry post pandemic

Posted on July 9, 2021 by admin

Cross ref to article

Looks like there are some issues post-pandemic within airline industry.

Passengers are coming back quicker than expected.

Airlines didn’t have people quit (because they had Federal funding to pay salaries) but they also could encourage people to early-retire, etc.

Pilots need to ramp back up again on training and recurrency.

In general, there are relatively fewer employees (pilots, FA’s, ground crew, etc).

All of this is going to lead to some delays and cancelled flights during Summer 2021.

 

This conversation with Honeywell execs (where I listed on 20210709) gives an interesting overview of the challenges and the forecasts thru 2021 and beyond

Posted in Aviation Industry, Post Pandemic | Leave a comment

Understanding Delta Variant components

Posted on July 7, 2021 by admin

Personal background: By February 2021 I have been double-vaccinated with Moderna mRNA to counter/protect from SARS-CoV-2 (aka Coronavirus aka COVID-19).

NOTE: Paul’s PSA is this: Get double-vaccinated (preferably Moderna or Pfizer) as soon as possible.

20210715 – Now the question is – is it more contagious or more severe? What’s the difference?  How do you measure?  What’s really important?  Note: There was an article in the NYT on July 15th, 2021 about this.  I need to research further.  Keep in mind that my primary go-to for any/all guidance is the CDC.  It’s too easy to get caught up with various MD’s giving opinions.

20210709 – Additional detail and research findings:  Looks like “It finds that the variant grows more rapidly inside people’s respiratory tracts and to much higher levels, researchers at the Guangdong Provincial Center for Disease Control and Prevention reported.”

Q: What does the Delta variant of COVID-19, responsible for COVID crisis in India, primarily mean?

A: They are collections of random mutations that cause the virus to act differently than original coronavirus.  They can be more contagious or resistant to treatment, which is the primary concern.

Q: What does it mean that the Delta variant (B.1.617.2) is more contagious?

A: The Delta variant was sourced in India and traveled to UK (becoming a dominant strain).  Prior to Delta, the Alpha variant (B.1.1.7) was dominant strain in UK because of increased transmissibility from original coronavirus.  In other words, Delta is very transmissible.  There is also a “Delta Plus” variant (B.1.617.2.1) which has an additional mutation (K417N) present in Delta.  In the USA, the Delta variant is now overtaking disease from Alpha variant in terms of percentages.

Q: How does Delta variant show up in hospital admittance rates?

A: The Delta variant is effectively doubling hospitalizations over Alpha variant, specifically with people that had not been vaccinated prior.

Q: Does prior vaccination (ideally mRNA) protect against Delta variant?

A: The key is partial vs full vaccination.  Partially vaccinated people are relatively more susceptible to Delta than Alpha infection.  The primary objective should be to become fully vaccinated as soon as possible.  Two does of vaccine were 88% effective against Delta vs 33% effective with one dose.

Q: How does Delta variant affect children?

A: The primary issue, focusing on UK, is that children under 12 have not been cleared for vaccination yet.  If this age issue is not addressed in the USA, we will probably see an increase in infections in children and adults.

Q: How are the Delta symptoms different from other strains?

A: Based on UK info, most common symptom is headache.  Maybe mistaken for common cold, sore throat, runny nose, fever.  But, it’s rare to develop a fever with a cold.  Delta cough and loss of smell symptoms are different than prior variants.

Q: What about the monoclonal antibody (emergency) treatments to counter SARS-CoV-2, as it relates to Delta variant?

A: Research shows these monoclonal antibody treatments are less efficient at the blocking the Delta variant.

Q: In the USA, if you’re double-vaccinated, do you need to wear a mask?

A: The CDC (as of XXX) are stating you don’t have to wear a mask.

Q: What’s the update on booster shots?

A: Currently research is being done to see if a booster is needed – durability, possibly integrating other things re: variants, etc.  Right now, the mRNA is doing well against Delta variant, so there has not been an immediate need for a booster.  Not sure when it will be needed, and to what degree.

A: Moderna says they are developing a booster candidate: a 50-50 mix of its currently authorized COVID-19 vaccine and another messenger RNA vaccine it has developed.

Q: What does Moderna have to say about variants?

A: Completed studies find the vaccine has a neutralizing effect against all COVID-19 variants, including: beta, delta, eta, and kappa variants.  While still highly effective against the Delta variant, the study showed the vaccine was less effective against it and certain other variants than against the original strain of the virus.  The antibody response against the Delta variant was about two times weaker than against the ancestral strain of the virus.

Q: What is long-haul symptoms mean?

A: Symptoms are shortness of breath, chest pain, fatigue, brain fog – that lasts for months beyond their infection.  This has occurred with people who had mild to moderate infections, and in some cases with asymptomatic infection.  The issue is that, even though you may not be hospitalized, there is a risk for long-haul symptoms.  This is also occurring in younger people.

Reference these articles:

What to know about the Delta Variant of COVID-19

Dr. Fauci on Delta variant, booster shots and masks for the vaccinated

Moderna says studies show its vaccine is effective against the Delta variant

U.S. Surgeon General on Delta variant, vaccine hesitancy and COVID long haulers

Posted in COVID-19 Pandemic, Delta Variant | Tagged | Leave a comment

For scheduling, program for Plus One

Posted on May 13, 2021 by admin

Disclaimers: The suggestion within this post may be primarily applicable to mass vaccination logistics, with initial swarm response.  Objective is not to find fault or lack.  Observations and thought process are the key discussion points.

Observation of County Public Health operation for COVID-19 vaccinations

  • Well laid out and fully staffed.
  • Several bays, allowing for multiple vaccinations delivered during one time-slot

Observation of appointment scheduling website

  • Initially designed to schedule only one person at a time

Experience as Social Work Case Worker, assisting with COVID-19 scheduling

  • People wish to travel together in groups of two and more
  • Some people have fear of needles (Trypanophobia), and find strength in going with others
  • Some people have assigned IHSS (In Home Support Service) workers or family members
  • Assisting with paperwork (filling out and printing) is a good means of securing a commitment

Prior roles which informed the suggestion

  • IT Systems Support Manager: Initial programming design is typically fields, records, individuals
  • Six Sigma Green Belt: Training in process improvement with an “end-to-end” awareness
  • Certified Hypnotherapist: Understanding of subconscious fears/phobias
  • MSW Social Worker: Person-in-Environment awareness (strengths, groups)

Ideal Outcomes

  • More people vaccinated in a given time
  • Facilitating the logistics of people being scheduled, who they go with, emotional/physical supports, etc

Suggestion for website scheduling interface

Note: Terminology my own, but premise is obvious

  • Schedule first appointment (and use as an anchor)
  • Ask if there are additional people to schedule at same day/time
  • Capture needed information and link with anchor appointment

Summary

  • Suggestion was well received by County Public Health for both first and second dose appointments
  • Now the system is managed by California Department of Public Health.  Not seeing ability to schedule “Plus One”.  Back to square one as of 20210513….
Posted in COVID-19 Pandemic, Scheduling | Leave a comment

COVID Information Videos – various

Posted on March 23, 2021 by admin

Here’s the first on when you are protected vs. vaccination.  I also attached the slides I used, in case that’s easier.  I have other videos planed on safety/efficacy, how they work, why you should consider vaccination, and perhaps a few myth busting ones (fertility etc)

Posted in COVID-19 Pandemic, Information | Leave a comment