SPECIALIZED RECORDING

STYLES

(THE S-O-A-P)
PURPOSE OF THE SOAP:
 TYPE OF PROBLEM ORIENTED
RECORDING
 SPECIAL FORMAT FOR PROGRESS OR
CASE NOTE ENTRIES
 ASSISTS WORKER IN IDENTIFYING
AND ASSESSING PROBLEM AREAS
AND DEVELOPING A PLAN OF ACTION
 USED IN INTERDISCIPLINARY
SETTINGS (ELIMINATES
DUPLICATION AND CONFUSION AS
TO WHAT’S BEING DONE)
PARTS OF THE S-0-A-P

(S)- SUBJECTIVE
(0)- OBJECTIVE
(A)- ASSESSMENT/ANALYSIS
(P)- PLAN
SUBJECTIVE DATA (S)

 CLIENT’S
STATEMENT OF
PROBLEM OR OTHER’S
STATEMENT OF PROBLEM AS
THEY PERCEIVE IT.
SUBJECTIVE EXAMPLE

 THE CLIENT REPORTS HE

HAS BEEN “DOWN” FOR THE
PAST WEEK.
 THE CLIENT’S SPOUSE
REPORTS THAT HER
HUSBAND HAS SEEMED
DEPRESSED THIS WEEK.
OBJECTIVE/OBSERVABLE DATA (O)

 WORKER’SRECORDING OF
FACTUAL DATA AND
OBSERVATIONS i.e.
STATISTICAL DATA SUCH AS
TEST RESULTS,
IDENTIFYING
INFORMATION, BEHAVIOR
OBSERVED DURING THE
SESSION
OBJECTIVE DATA CONTINUED
 ANY INFORMATION THAT
COULD BE TAKEN FROM AN
INFORMATION SHEET OR
REFERRAL FORM. I.E. BAC WITH
DUIS, PREVIOUS ARREST
HISTORY, PREVIOUS
TREATMENT HISTORY, ETC.
OBJECTIVE EXAMPLE
 THE CLIENT WAS ADMINISTERED A
BECK DEPRESSION INVENTORY AND
SCORED A 25.
 THE CLIENT STARTED HIS JOB AT
MCDONDALDS THIS WEEK.
 THIS WORKER OBSERVED THE
CLIENT LOOKING AWAY AS SHE
TALKED ABOUT HER MOTHER.
 THIS THERAPIST OBSERVED THE
CLIENT CRYING AS HE TALKED
ABOUT HIS DIVORCE.
ASSESSMENT (A)

 THEWORKER
ANALYZES/ASSESSES THE
MEANING OF THE
SUBJECTIVE DATA AND THE
OBJECTIVE DATA AND
WHAT IT MIGHT MEAN.
(CLINICAL JUDGMENT)
ASSESSMENT EXAMPLE
 THE CLIENT REPORTS FEELING
HAPPIER BUT THIS COUNSELOR
NOTICED HE SELDOM SMILED OR
MADE EYE CONTACT DURING THE
SESSION. IT COULD BE THE
CLIENT IS NOT AWARE OF HIS
NONVERBAL COMMUNICATION
OR IS TRYING TO PROJECT HE IS
HAPPIER WHEN NOT REALLY
FEELING THAT WAY.
ASSESSMENT EXAMPLE
 THE CLIENT SEEMED CONGRUENT
WITH HIS ANGER AS TO HIS
LAST CONVERSATION WITH HIS
EX-WIFE, AS HIS VOICE WOULD
RAISE WHEN DISCUSSING THEIR
PHONE CALL. IT WOULD APPEAR
HE IS STILL FEELING RESENTFUL
AND STRUGGLING WITH THE
MARRIAGE ENDING.
PLAN OF ACTION (P)

 THEWORKER’S STATEMENT
AS TO A PLAN OF ACTION
TO WORK ON THE
IDENTIFIED PROBLEM (CAN
BE BOTH ON PART OF THE
WORKER AND THE CLIENT)
PLAN EXAMPLE

 BEFORETHE NEXT SESSION

THIS COUNSELOR WILL
CONSULT WITH THE
PSYCHIATRIST ABOUT
POSSIBLE MEDICATION FOR
THE CLIENT.
PLAN EXAMPLE
 THE CLIENT HAS AGREED TO
BEGIN JOURNALING ABOUT HIS
FEELINGS AT NIGHT BEFORE HE
GOES TO BED AND TO BRING HIS
JOURNAL EACH SESSION TO
SHARE WITH THIS COUNSELOR.
EXAMPLE
 COUNSELING SESSION
ASSIGNMENT
 TYPE OUT AND DOUBLE SPACE A S-0-
A-P CASE NOTE ENTRY FOR ONE OF
THE TWO CASE STUDIES BASED UPON
YOUR DEGREE
 INCLUDE ALL PARTS OF THE S-O-A-P.
 USE (S)-(O)-(A)-(P) TO IDENTIFY
EACH PART OF THE SOAP.
 PUT YOURSELF IN THE PLACE OF THE
WORKER. (THIS WORKER…)
 WRITE IN COMPLETE SENTENCES AND
CAREFULLY PROOFREAD