Below is a fictional example of a progress note in the SOAP (Subjective, Objective, Assessment, Plan) format. For the purposes of this sample progress note, the focus is on the content of the progress note, rather than the format.

Is patient taking medication for addiction treatment as directed (dose, administration, etc.)? Is patient experiencing any of the following? Comments: Has patient used any substances? (Check all that apply) Does patient have access to nasal naloxone? Is …

May 19, 2022 · Different intake and progress notes and follow-ups in mental health, the importance of patient documentation in psych.

Mar 12, 2025 · In this article, we’ll walk you through what SOAP notes are, how to write them, and when they might be the most helpful note type to use. We’ll also provide a SOAP note example based on a real-life scenario, and an Upheal template that you can download for free.

Explain the plan for treatment, including goals, interventions, frequency of sessions, referrals to other professionals, and any follow-up needed. For example: Provide empathy, support, and coping strategies to improve mood and functioning.

Substance abuse treatment is a complex and multifaceted process that requires careful documentation and planning. In this blog, we will explore the specifics of BIRP notes for substance abuse treatment, offering insights and examples to demonstrate their effectiveness.

We discussed treatment options for opioid addiction in detail (methadone, buprenorphine, naltrexone, abstinence only). Would like to start suboxone. We discussed treatment requirements, the induction, insurance issues and benefits of counseling. Handouts on the above, suboxone consent and WA Recovery helpline card given.

This page provides 10 comprehensive SOAP note examples commonly encountered in social work practice. Each example follows standard documentation guidelines and demonstrates proper clinical documentation for various client situations, from mental health concerns to child protective services and community resource coordination. 1.

Oct 25, 2021 · Therapist reviewed safety plan with client to identify triggers, coping strategies and supports, as well as ways to cope following substance use. Client agreed to modifications made to safety plan, as well as intent to attend 3 AA meetings and utilize sponsor.

♦ Example: Beginning to own responsibility for consequences related to drug use. P = Plan for future clinical work. Should reflect interventions specified in treatment plan including homework assignments. Reflect follow-up needed or completed. ♦ Example: Begin to wear a watch and increase awareness of daily schedule.