SOAP note example for Social Worker

SOAP note example for Social Worker

Subjective

Martin has had several setbacks, and his condition has worsened. Martin reports that the depressive symptoms continue to worsen for him. He feels that they are 'more frequent and more intense. Depressive symptomatology is chronically present. He expressed that he has experienced no change in anhedonia and his energy levels are lower than they have been in the past month. He states that he now constantly feels fatigued both mentally and physically. Martin finds concentrating difficult, and that he quickly becomes irritated. Feelings of worthlessness and self-loathing are described. Martin describes experiencing suicidal ideation daily but that he has no plan or intent to act.

Objective

Martin denies any hallucinations, delusions, or other psychotic-related symptomatology. His compliance with medication is good. He appears to have gained better control over his impulsive behavior as they are being observed less frequently. Martin appears to have lost weight and reports a diminished interest in food and a decreased intake.

Assessment

The therapeutic focus of this session was to ascertain the severity of Martin's ongoing depression and help Martin increase his insight and understanding of his depression. The content of the therapy was to focus on coping with depression and tools that can be used to enable Martin to make progress. Martin presents as listless, distracted, and minimally communicative. He exhibits speech that is normal in rate, volume and articulation is coherent and spontaneous. Language skills are intact. There are signs of severe depression. Body posture, eye contact, and attitude portray a depressed mood. The slowness of physical movement helps reveal depressive symptomatology. There are no apparent signs of hallucinations, delusions, or any other indicators of psychotic processes. Associations are intact, and thinking is logical. He appears to have good insight. The thought process seems to be intact, and Martin is fully orientated. Martin describes experiencing suicidal ideation daily but that he has no plan or intent to act. Martin's behavior in this session was cooperative and attentive.

Plan

Martin continues to require outpatient treatment. He consistently exhibits symptoms of major depressive disorder, and which interfere with his day-to-day functioning and requires ongoing treatment and support. 1.  Meet with Martin again in 2 days, Friday, 20th May 2.  Martin to follow his safety plan if required 3.  Martin to make his family aware of his current state of mind

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