Case Notes

For the purposes of this application, I have chosen to use the SOAP and DAP format for the family counseling session with Dr. Buckley (Laureate Education, Inc., 2010). For routine progress notes, either format works well to document the issues of counseling and progress made therein. Both notation formats have strengths and limitations but equally accomplish the essential task of recordkeeping in counseling.

SOAP Notes

Subjective

Father says he is concerned about his daughter's drinking and that his wife and daughter are drinking buddies. Mother says she and daughter are close friends and have a drink together occasionally. Mother says her husband treats her like a trophy so the world will see his success. Daughter says Father thinks she is a dancing monkey, and has no idea what she wants in her life. Father says he shows his love for his family by providing for them. He said part of his role is to tell his daughter what she wants, because she is too young to know for herself.

Objective

Proxemic behavior suggests mother and daughter allied against father (mother and daughter sit together, father sits alone. Mother and daughter use the word 'we' when talking about 'their' feelings. Father and Mother clearly on different sides of issues related to daughter. Mother is overly dependent on daughter for friendship and affection. Daughter likes Mom to be "cool" - she lets her drink, is open with her friends, and lets her do what she wants.

Assessment

The parents' relationship seems to have deteriorated over time; they share little to no affection and friendship. Father and daughter have an antagonistic relationship. Mother and

daughter are enmeshed in an unhealthy relationship. Mother seems overly dependent on daughter for emotional needs. Need to rule out daughter's alcohol abuse. Father has a fairly linear perspective on family life.

Plan

Strengthen parents relationship - date night once per week. Strengthen mother's sense of self and developing other friend relationships by becoming involved in something outside the home. Father and daughter will spend alone time together each week. Father will practice thinking about his role in the family differently-being a loving father rather than provider.

Benefit and Limitation of SOAP Notes

As long as counselors provide enough information, this notation format is an easy and efficient way of keeping records in a basic format that can be developed according to counselors' personal style of recordkeeping. Quinn and Gordon (2003) believe this format is widely used and understood by the majority of healthcare professionals, which is a benefit for the profession. Delitto and Snyder-Mackler (1995) believe the brevity of this format may preclude using it to assess progress, and emphasize the need to record adequate information.

DAP Notes

Data

The family comes to therapy because of daughter's drinking. Father is concerned about the drinking and also about the mother allowing the daughter to drink. Mother and daughter report having a close relationship, and mother and father report being distant. Mother and daughter believe the father uses them as trophies. Daughter expresses having a good relationship with her mother, but that her father does not know her or have any idea of who she is and what she wants. Father states he expresses his love by providing for his family.

Assessment

Parental relationship has deteriorated over time; mother and daughter became closer while the father became more distant from both the mother and daughter. Mother and daughter have become enmeshed and are somewhat estranged from Dad. Dad perceives his relationship to both in a fairly linear way and expresses his love in providing for the family rather than in overt emotional ways. He learned this role from his father. Daughter does some drinking with Mom and also with friends, so further investigation of her drinking behavior is warranted.

Plan

Have Mom get involved with a group or cause outside the home to strengthen her sense of self and extricate her from the enmeshed relationship with her daughter. Parents need to strengthen their relationship with a date night. Father and daughter need to have some alone time to create a relationship separate from mother. Dad needs to learn to think differently about roles he's learned regarding parenting, fatherhood and being a husband.

Benefit and Limitation of DAP format

This notation format is a quick and efficient way to keep information and track client progress. It can be accomplished in 10 minutes and between counseling sessions when necessary. One limitation is that although this type of notation is efficient and organized, it may tend to oversimplify the therapeutic process (Zuckerman, 2008).

Conclusion

Effective documentation in counseling protects counselors and helps them do a better job of monitoring client progress. Zuckerman (2006) believes finding a personally effective form of notation that will be used consistently helps keep counseling on track and protects both the client
and counselor in legal proceedings and other circumstances.

References

Delitto, A. & Snyder-Mackler, L. (1995). The diagnostic process: examples in orthopedic physical therapy. Physical therapy, 75:203-211.

Laureate Education, Inc. (Executive Producer). (2010). Techniques in counseling. Baltimore, MD: Author.

Quinn, L., & Gordon, J. (2003). Functional outcomes: Documentation for rehabilitation. St. Louis, Mo: Saunders.

Zuckerman, E. L. (2008). The paper office (4th ed.). New York, NY: Guilford Press.