S.O.A.P. Notes

SOAP Notes

[Name of the Writer]

[Name of the Institution]

Subjective

“He goes out drinking all night and I get so furious. I’m done going around town trying to find him at bars.” Persistent drinking habit of her husband has caused her disappointment. Cl. stated that he has no aggressive behaviors at home such as child abuse and viciousness. He has a habit of drinking from earlier stages of life. No other medical problem has been observed yet but the situation is aggravating day by day.

Objective

Vital signs include no aggression and violence. She has been concerned for family life and impression of drinking on children ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1al34414h4","properties":{"formattedCitation":"{\\rtf \\super 1\\nosupersub{}}","plainCitation":"1"},"citationItems":[{"id":117,"uris":["http://zotero.org/users/local/p8kwKNoG/items/6KHCWKYH"],"uri":["http://zotero.org/users/local/p8kwKNoG/items/6KHCWKYH"],"itemData":{"id":117,"type":"article-journal","title":"Assessment of SOAP note evaluation tools in colleges and schools of pharmacy","container-title":"Currents in Pharmacy Teaching and Learning","page":"576-584","volume":"9","issue":"4","author":[{"family":"Sando","given":"Karen R."},{"family":"Skoy","given":"Elizabeth"},{"family":"Bradley","given":"Courtney"},{"family":"Frenzel","given":"Jeanne"},{"family":"Kirwin","given":"Jennifer"},{"family":"Urteaga","given":"Elizabeth"}],"issued":{"date-parts":[["2017"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} 1. Family history of drinking has complicated the situation ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1d9e1p48e","properties":{"formattedCitation":"{\\rtf \\super 1\\nosupersub{}}","plainCitation":"1"},"citationItems":[{"id":117,"uris":["http://zotero.org/users/local/p8kwKNoG/items/6KHCWKYH"],"uri":["http://zotero.org/users/local/p8kwKNoG/items/6KHCWKYH"],"itemData":{"id":117,"type":"article-journal","title":"Assessment of SOAP note evaluation tools in colleges and schools of pharmacy","container-title":"Currents in Pharmacy Teaching and Learning","page":"576-584","volume":"9","issue":"4","author":[{"family":"Sando","given":"Karen R."},{"family":"Skoy","given":"Elizabeth"},{"family":"Bradley","given":"Courtney"},{"family":"Frenzel","given":"Jeanne"},{"family":"Kirwin","given":"Jennifer"},{"family":"Urteaga","given":"Elizabeth"}],"issued":{"date-parts":[["2017"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} 1. She is concerned and looking for long term solution. She is confused about treating and managing the situation of her husband at home. She sensed frustrated when she found her husband drunk every night.

Assessment

She needs support and encouragement for managing the state of her husband. Her husband has unceasing drinking routine and has least interest in family life. Assessing the situation in searching for a permanent solution and blaming herself for the condition of her husband. Needs regular appointments to support and encourage her husband to stop drinking. Considering divorce or separation would not help him out. She is assuming that there is a need of better intervention therapies for better consequences.

Plan

She blames herself for her husband’s drinking habit and is honest in that opinion. She is supportive and helpful and wants to improve the condition of her husband. Providing psychological health education concerning husband’s alcohol use. She is seeking for an appointment at Al-Anon for support and to oppose negative self-ideations. Awareness regarding mental health is mandatory for her husband ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a26npcnhuqg","properties":{"formattedCitation":"{\\rtf \\super 2\\nosupersub{}}","plainCitation":"2"},"citationItems":[{"id":120,"uris":["http://zotero.org/users/local/p8kwKNoG/items/FVEIB6RF"],"uri":["http://zotero.org/users/local/p8kwKNoG/items/FVEIB6RF"],"itemData":{"id":120,"type":"article-journal","title":"Clinical validation of reduced alcohol consumption after treatment for alcohol dependence using the World Health Organization risk drinking levels","container-title":"Alcoholism: clinical and experimental research","page":"179-186","volume":"41","issue":"1","author":[{"family":"Witkiewitz","given":"Katie"},{"family":"Hallgren","given":"Kevin A."},{"family":"Kranzler","given":"Henry R."},{"family":"Mann","given":"Karl F."},{"family":"Hasin","given":"Deborah S."},{"family":"Falk","given":"Daniel E."},{"family":"Litten","given":"Raye Z."},{"family":"O'Malley","given":"Stephanie S."},{"family":"Anton","given":"Raymond F."}],"issued":{"date-parts":[["2017"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} 2. Regular medical checkups are mandatory for patients with drinking habits. Regular observation of blood pressure and other vitals such as pulse, blood sugar levels and psychological health assessment ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"afiarhv4k2","properties":{"formattedCitation":"{\\rtf \\super 1\\nosupersub{}}","plainCitation":"1"},"citationItems":[{"id":117,"uris":["http://zotero.org/users/local/p8kwKNoG/items/6KHCWKYH"],"uri":["http://zotero.org/users/local/p8kwKNoG/items/6KHCWKYH"],"itemData":{"id":117,"type":"article-journal","title":"Assessment of SOAP note evaluation tools in colleges and schools of pharmacy","container-title":"Currents in Pharmacy Teaching and Learning","page":"576-584","volume":"9","issue":"4","author":[{"family":"Sando","given":"Karen R."},{"family":"Skoy","given":"Elizabeth"},{"family":"Bradley","given":"Courtney"},{"family":"Frenzel","given":"Jeanne"},{"family":"Kirwin","given":"Jennifer"},{"family":"Urteaga","given":"Elizabeth"}],"issued":{"date-parts":[["2017"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} 1. Cognitive behavioral therapy would also be recommended. Clients with persistent habits of drinking often develop cardiovascular disorders as well as high risk of developing lung cancer. A regular medical check-up can help assess the conditions in earlier stages.

End Notes

Sando KR, Skoy E, Bradley C, Frenzel J, Kirwin J, Urteaga E. Assessment of SOAP note evaluation tools in colleges and schools of pharmacy. Curr Pharm Teach Learn. 2017;9(4):576-584.

Witkiewitz K, Hallgren KA, Kranzler HR, et al. Clinical validation of reduced alcohol consumption after treatment for alcohol dependence using the World Health Organization risk drinking levels. Alcohol Clin Exp Res. 2017;41(1):179-186.