Problem: Jason is 17 years of age and comes to you in your role as a case manager of a youth support service stating he "can't hack his Dad anymore" and wants to move out of the home. Jason's mother Vivian died 6 months earlier and he has two siblings aged 14 and 11, both siblings remain living with his father Yarran. Jason is doing his VCE at school and is currently in Year 11. He states that ever since his mother died his father has been drinking a lot and has become aggressive toward the kids. Jason is keen to get on with his studies and he comes to you for assistance.
Based on this case study, case notes need to be formulated:
The case notes format is SOAP (Subjective, Objective, Assessment, and Plan).
1. Subjective
Information relevant to what the client reveals in the session and/or from the onboarding notes received before the meeting.
2. Objective
The factual information - details may include things like, the client's appearance, orientation, behaviours, mood or affect.
3. Assessment
Your impressions and interpretation of the objective and subjective information. This documentation may include impressions related to factors such as mood, orientation, risk of harm as well as assessment of progress towards goals. Here you want to describe your impressions. For example, client appears to understand the new goal.
4. Plan
Document what the next step is for the client, the anticipated frequency and duration of therapy, short- and long-term goals as well as any new goals. Note homework or tasks you've given your client.