In Topic 5, you created a treatment plan for your client. Create a SOAP note that would go in the client’s chart following the visit. Post the SOAP note as a reply to this discussion thread. For follow-up discussion, evaluate at least two of your peers’ SOAP notes. Would you have documented anything differently? Why or why not?
In Topic 5, you created a treatment plan for your client. If your client was to attend a group therapy session, write a progress note for that client’s participation in that group. How is writing a group progress note different than an individual progress note?
Treatment Plan Template
Based on the information collected in week 4, complete the following treatment plan for your client Eliza. Be sure to include a description of the problem, goals, objectives, and interventions. Remember to incorporate the client’s strengths and support system in the treatment plan.
When completing a treatment plan with a client, be sure to include a diagnosis from the DSM V. This would include the diagnosis, specifiers, and code from the DSM. The ICD Code should also be included.
Include a minimum of two overall goals, at least two objectives for each goal, and at least one intervention for each objective. If you have more than two overall goals, simply copy and paste the chart below.
Client:
Eliza
Date:
17th December 2021
Age:
18 years
DOB:
January 15th, 2003
ICD-10 Diagnosis (Code)
Adjustment Disorder (309.28)
Alcohol Use Disorder (305.00)
DSM Diagnosis (Code and Description)
F43.23
F10.10
Description of the Problem:
The patient is experiencing anxiety, stress, and low self-esteem due to her adjustment disorder.
Goal # 1: Reducing the patient’s anxiety symptoms.
Objective(s):
Intervention(s):
Frequency:
Target Date:
1. Stabilizing patient’s mood.
Cognitive Behavioral Therapy
Skills Training
Referral to Psychotropic Medication and consultation
☐ Weekly ☐ Bi-Weekly
☐ Monthly ☐ Other: _________________
Modality:
☐ Group ☐ Individual
☐ Family
14th January 2022
2. Increasing patient’s skills of coping with anxiety.
Cognitive Behavioral Therapy
Relaxation Techniques Training
Skills Training
Journaling
☐ Weekly ☐ Bi-Weekly
☐ Monthly ☐ Other: ___________________
Modality:
☐ Group ☐ Individual
☐ Family
14th January 2022
Description of the Problem: The patient has Alcohol Use Disorder which needs to be addressed because she is in a campus that does not allow alcohol.
Goal # 2: Ensuring that the patient abstains from alcohol and any other drugs.
Objective(s):
Intervention(s):
Frequency:
Target Date:
1. Ensuring the patient attends therapy for alcoholism support and prevention.
Substance Use Assessment
Attending Meetings
Obtaining sponsor
☐ Weekly ☐ Bi-Weekly
☐ Monthly ☐ Other: ____________________
Modality:
☐ Group ☐ Individual
☐ Family
14th January 2022
2. Eliminating and decreasing self-harm behaviors
Cognitive Behavioral Therapy
Skills Training
Attending Group Therapy
☐ Weekly ☐ Bi-Weekly
☐ Monthly ☐ Other: ____________________
Modality:
☐ Group ☐ Individual
☐ Family
14th January 2022
References
Poulsen, R., Fisker, J., Hoff, A., Hjorthøj, C., & Eplov, L. F. (2017). Integrated mental health care and vocational rehabilitation to improve return to work rates for people on sick leave because of exhaustion disorder, adjustment disorder, and distress (the Danish IBBIS trial): study protocol for a randomized controlled trial. Trials, 18(1), 1-15.
Campbell, E. J., Lawrence, A. J., & Perry, C. J. (2018). New steps for treating alcohol use disorder. Psychopharmacology, 235(6), 1759-1773.
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