SOAP Progress Notes

Client: Savanah

Session #: 1

Date: 04/17/16

Therapist: Hannah M. Burleson

S Subjective: Completethesubjectivesectionofthenoteswithinformationthatthepatienthasrelateddirectlytoyou.Thissection
includesopinionbasedinformationfromthepatient:feelings,concerns,goalsfortherapy,etc.Includepertinentcommentsfrom
friends,family,caseworkersorotherpeopleclosetotheclient.

Today was Savanahs initial therapy session. She reported that she was there at the requirement of her mother,
who is concerned that her desire to be healthy is getting extreme. Savanah referenced a couple of events that
caused her mother to become concerned: 1) a couple of weeks ago, Savanah passed out while running, and 2)
Savanah has not had her normal period in four months. Savanah shared that she has lots of friends, is involved
in cheerleading, and is dating a star football player. She indicated that sometimes it is a lot of pressure to
maintain a good image and stay thin. Savanah stated, I dont think there is anything wrong with wanting to be
healthy. However, she admitted that feeling lightheaded, getting headaches, losing her period, and sometimes
passing out are not indicators of good health. Savanah stated, I want to get help and be in control of my life
rather than the other way around.
O Objective: Writeonlyfactbasedinformationintheobjectivesectionofthenotes.Thisinformationincludesquantitative,
verifiableevidence,suchaswhatcanbedirectlyobservedbythefivesensesandbyscientificmeasurements.Thiscanincludethe
clientsappearance,anymedicalmeasurementstakenandobviousbehavior.

Savanah, a 17-year-old Caucasian female, presented to the session on time and oriented times three. Mood,
affect, appearance, and personal hygiene were appropriate to the situation and session content. She was
expressive and open throughout the session.
A Assessment: Analyzetheclientsbehaviorandproblemsintheassessmentsectionofthenotes.ThissectionisusedforaDSM
diagnosis.

DSM 5Diagnosis:AnorexiaNervosa,307.1(F50.1),RestrictingType,Mild
P Plan: CreateaplanfortheclientstreatmentandrecorditinthissectionofyourSOAPnotes.Thissectioncancontainshort
termgoalsfromthemastertreatmentplanwithrecommendationsforfuturesessions.

ShortTermGoalsofTreatment:
Goal:(increase/decreasepersonalissue,behavior,orrelationaldynamic)to(increase/reducesymptom)
1.ClientwillincreaseBMItoreducesymptomsofAnorexiaNervosa.
Measure:ClientsBMIwillreachthenormalrangeunderthecarefuldirectionofacollaboratingteamof
professionals
TreatmentInterventions:NutritionalTherapy
2.Clientwillincreasecommunicationwithhermomtoreduceriskofmisunderstandingsaboutbeinghealthy
Measure:Clientwilldemonstrateabilitytocommunicateclearlyandeffectivelywithhermotherregarding
hermothersexpectationsaboutbeinghealthy.

SOAP Progress Notes

TreatmentInterventions:FamilyTherapy
3.Clientwillincreasenutritionalknowledgetoincreaseabilitytomaintaingoodhealthinthelongterm.
Measure:Clientwilldemonstrateasolideducationonnutrition/healthfuleating
TreatmentInterventions:NutritionalTherapy
Future Recommendations:
No revisions to the current treatment plan are necessary at this time.
Hannah M. Burleson
Therapist

04/17/16
Date