Note Examples
Example SOAP

Example SOAP

SUBJECTIVE

Presentation

  • Chief Complaint: The family reported ongoing issues with communication breakdowns and arguments. However, the frequency and intensity of conflicts has reduced over the past month of therapy.
    • Quote (Chief Complaint): "We're still struggling to communicate calmly, but the big blowout fights have gone down." - Father
  • Impairments And Challenges: The parents state arguments disrupt family functioning 1-2 times per week. The daughter continues to isolate herself when upset.
    • Quote (Impairments And Challenges): "The arguments make me really anxious and then I just go to my room to get away from it." - Daughter
  • Communication Patterns: Family members listen better but still frequently interrupt or talk over each other when emotions escalate.
    • Quote (Communication Patterns:) "We'll be calm at first but then we all start raising our voices and no one hears what the other is saying." - Mother
  • Conflict Resolution: Family has improved ability to de-escalate from arguments, but continue to struggle resolving core issues.
    • Quote (Conflict Resolution): "We've gotten better at taking a time out when tensions rise, but we need help solving our disagreements once we cool down." - Father
  • Family Dynamics: Parents are more involved in daughter's life but she continues keeping some feelings private.
    • Quote (Family Dynamics): "We've been trying to do more together as a family, but sometimes it still feels like she shuts us out." - Mother
  • Family Roles: Parents allowing daughter more autonomy but still revert to overcontrol at times. Daughter becoming more responsible.
    • Quote (Family Roles): “They've lightened up on the rules some, but then they'll crack down again over every little thing." - Daughter
  • Family Rules And Boundaries: Family has negotiated some rules to allow daughter more age-appropriate independence. Some ongoing tensions around curfew.
    • Quote (Family Rules And Boundaries):"I know they worry, but I wish my curfew could be later like my friends'." - Daughter

OBJECTIVE
Clinical Assessment:

  • Assessment Tool: Family Communication Scale, Session Check-In Form.
  • Results: Family's average communication score improved from 2.3 to 3.1 out of 5 over past month of treatment. Daughter's session engagement increased from 3 to 4 out of 5.
  • Status: Assessments will continue weekly to track progress on goals.

Interventions:

  • Therapeutic Approach Or Modality: Cognitive-behavioral, Communication Skill Building, Parent Education.
  • Psychological Interventions:
    • Practiced reflective listening during enactment.
    • Discussed balancing teenage autonomy and parental authority.
    • Assigned homework practicing "I feel" statements.
  • Rationale: Interventions targeted improving family communication and adjusting family roles and rules to support healthy adolescent development.

ASSESSEMENT

Progress And Response:

  • Response To Treatment: Family has shown good compliance with treatment. Communication slowly improving.
  • Specific Examples Or Instances: Family's average communication score has increased over the past month.
  • Quote (Progress): "I feel like we're starting to understand each other better." - Daughter
  • Challenges To Progress: Family still struggles with emotional escalation and talking over each other. Core issues remain unresolved.
  • Therapist Observations And Reflections: Family is slowly building insight and skills but needs more work resolving underlying sources of conflict.
  • Therapeutic Alliance: Alliance with daughter remains tentative at times. Will continue efforts to strengthen.

PLAN

Follow Up Actions And Plans:

  • Homework: Practice "I feel" statements during family discussions. Continue communication scale ratings.
  • Plan For Future Session: Next session will focus on identifying core family conflicts and practicing conflict resolution skills.
  • Plans For Continued Treatment: Family will continue weekly sessions with reassessment in 4 weeks.
  • Coordination Of Care: No current coordination of care indicated.