In Brief
Documenting therapy sessions with clients who are children or adolescents requires a unique approach, as their needs, treatment, and challenges differ from those of adult clients. If you’re already comfortable with SOAP notes, there are some adjustments you can make to account for the specific needs of your clients that are not yet adults. Understanding the key components and benefits of this note-taking format helps therapists maintain thorough, efficient records while focusing on providing the best possible care for their young clients.
Let’s take a look at the essentials of writing SOAP Notes for Children and Adolescents, providing examples, templates, and tips to help you integrate this valuable tool into your practice.
What are SOAP Notes for Children and Adolescents?
Like any other SOAP note, they provide a structured, comprehensive method for documenting therapy sessions with your clients who are children or adolescents. Some key characteristics are that your notes:
- Follow the SOAP format: Subjective, Objective, Assessment, and Plan
- Focus on the unique needs and challenges of pediatric/adolescent clients
- Include information gathered from the child, parents, caregivers, and other relevant sources
- Document the child's progress, treatment goals, and any necessary adjustments to the treatment plan
Benefits of Using SOAP Notes for Children and Adolescents in Your Practice
Including these specific SOAP notes in your practice brings several important benefits:
- Comprehensive Documentation: This format ensures that every relevant aspect of the therapy session is recorded, such as subjective and objective observations, assessment of the child's progress, and the treatment plan moving forward. A complete record of each session is vital for maintaining continuity of care and tracking the child or adolescent's development over time.
- Improved Communication: SOAP Notes for Children and Adolescents promote effective communication among healthcare providers, including therapists, pediatricians, and other specialists involved in their care. A standardized format makes it easy to share and understand information, leading to better collaboration and coordination of care.
- Enhanced Treatment Planning: The structured nature of SOAP Notes helps therapists identify patterns, monitor progress, and make informed decisions about treatment strategies for younger clients. Regularly reviewing these notes allows for timely adjustments to the treatment plan based on the child or adolescent's specific needs and response to interventions.
- Increased Efficiency: Once you become familiar with writing SOAP Notes specifically for Children and Adolescents, documenting sessions becomes more streamlined and efficient. A clear structure to follow saves time and ensures that important details are not missed, allowing you to focus more on providing quality care to your young clients.
- Legal and Ethical Compliance: As with all note types for clients of any age, maintaining accurate and thorough documentation is a legal and ethical responsibility for therapists. SOAP Notes demonstrate your adherence to professional standards and serve as a valuable record in case of any legal or regulatory inquiries.
Step-by-Step: Writing SOAP Notes for Children and Adolescents
Creating a SOAP Note for your clients under 18 requires a systematic approach to ensure you capture all relevant information efficiently. Here's a step-by-step guide to help you write effective SOAP Notes specifically for Children and Adolescents:
Before the Session
- Review previous notes: Look over the child's history, treatment plan, and progress by checking previous session notes.
- Prepare materials: Get any necessary assessment tools, worksheets, or activities ready for the upcoming session.
- Set session goals: Reflect on the main objectives for the session based on the child's treatment plan, recent progress, and presentation in the last session. Be prepared to change course if clinically appropriate.
During the Session
- Subjective (S): Record the child or adolescent's personal experience, including their thoughts, feelings, and any concerns shared by themselves or their parents or caregivers. Use direct quotes when appropriate.
- Objective (O): Note observable behaviors, such as the child’s appearance, affect, and engagement in the session. Record any significant non-verbal cues or interactions.
- Assessment (A): Evaluate the information gathered during the session, considering the child's progress toward treatment goals. Identify any new insights, patterns, or areas of concern.
- Plan (P): Describe the next steps in the child or adolescent’s treatment, including any changes to the treatment plan, homework assignments, or referrals. Schedule the next session and communicate the plan with your client and their parents or caregivers.
After the Session
- Review and finalize: Go through your progress note to ensure clarity, completeness, and accuracy. Make any necessary edits or additions while the session is still fresh in your mind.
- Update the treatment plan: Add any changes discussed during the session to the child's overall treatment plan.
- Communicate with other providers: Share relevant information from the session with other healthcare professionals involved in the child's care, such as pediatricians or school counselors, as needed.
Pediatric SOAP Note Examples
To get a clearer picture of how to use SOAP Notes for the children and adolescents in your practice, let's look at three illustrative examples. The below are abbreviated versions of your progress notes, so aim to be more comprehensive, yet concise as you write your notes.
Example 1
Name: Ellie Johnson
Age: 10 years old
Gender: Female
Grade: 5th grade
Ethnicity: Caucasian
Primary Diagnosis: Generalized Anxiety Disorder
S: Client reports feeling worried about an upcoming test, having trouble sleeping, and experiencing stomachaches. Parents mention increased irritability and avoidance of school-related tasks.
O: Client appears restless, fidgeting with hands, and has difficulty maintaining eye contact. Breathing rate appeared to be slightly rapid and client complaining of a stomachache during session.
A: The therapist engaged client in an art therapy activity to promote the client’s sense of confidence in self expression and enhance skills in her ability to self-soothe. The child's anxiety appears to affect their family relationships and academic performance. The client is actively participating in session although reports not meeting goal to use healthy coping skills outside of session.
P: Introduce relaxation techniques, such as deep breathing and progressive muscle relaxation. Assign homework to practice these techniques daily. Schedule a follow-up session in one week.
Example 2
Name: Lucas Martinez
Age: 14 years old
Gender: Male
Grade: 9th grade (Freshman in high school)
Ethnicity: Hispanic
Primary Diagnosis: ADHD
S: The therapist acknowledged to the client his parents’ email to the therapist reporting that he is having difficulty focusing on homework, often loses things, and is easily distracted in class. The client hung his head when hearing this feedback and expressed frustration with his inability to concentrate.
O: Throughout the session, the client moved constantly in their seat, played with objects on the desk, and required redirection and the therapist repeating themselves due to trouble following the conversation. The therapist utilized developmentally appropriate mindfulness techniques to support client in improving focus and decreasing distractibility. Client stated he enjoyed the techniques and agreed to use them at school.
A: The client’s inattention and hyperactivity appear to significantly impair academic and social functioning. The client denied substance use. The client reported no progress toward goal of turning homework in thoroughly completed and on time.
P: Discuss behavioral strategies with parents, such as establishing a consistent routine and using positive reinforcement. Recommend a consultation with a psychiatrist to discuss potential medication options. Schedule a follow-up session in two weeks.
Example 3
Name: Mia Thompson
Age: 13 years old
Gender: Female
Grade: 8th grade
Ethnicity: African American
S: Client reports persistent feelings of sadness, loss of interest in previously enjoyed activities, and difficulty concentrating. Parents note no changes in appetite and stated client is very difficult to wake in the morning. The client reported having difficulty falling asleep at night.
O: Client presented to session appearing withdrawn, with a flat affect, and speaking in a monotone voice. Therapist provided the client with psychoeducation on cognitive distortions, including supporting the client identifying thoughts that prevent them from making progress toward the treatment goal. The client responded to therapist's questions although was difficult to engage in a back-and-forth conversation.
A: The child's depressive symptoms appear to cause significant distress in social, family, and academic areas of life. The client reports making no progress toward their goal to engage in one social or family activity out of their bedroom.
P: Continue using cognitive behavioral therapy techniques, such as identifying and challenging negative thoughts. Encourage participation in pleasurable activities. Meet with parents to provide psychoeducation on depression. Discuss the potential need for medication with parents and recommend a psychiatric evaluation. Schedule a follow-up session in one week.
Writing Effective SOAP Notes for Children and Adolescents
Incorporating these tips into your pediatric SOAP Note writing process will help you create more effective and efficient documentation:
- Focus on clarity and brevity: Use straightforward language and avoid jargon or overly complex terms. Keep your notes focused and concise, ensuring that the most important information is accessible.
- Maintain a consistent format: Follow the standard SOAP format (Subjective, Objective, Assessment, Plan) for each note. This consistency makes it easier for you and other healthcare providers to quickly find and understand relevant information.
- Be detailed and objective: Include specific details and observations in your notes, rather than generalizations. Use objective language to describe the child or adolescent's behaviors, symptoms, and progress, avoiding subjective opinions or judgments.
- Ensure accuracy and thoroughness: Double-check your notes for accuracy, ensuring that all relevant information is included. Complete your notes as soon as possible after the session to minimize the risk of forgetting important details.
- Use patient-centered language: Write your notes with the understanding that the child and their family may read them if requested or subpoenaed. Use respectful language that focuses on your client’s strengths and progress, rather than deficits or limitations while also acknowledging impairments that demonstrate medical necessity.
- Include evidence-based practices: When documenting your assessment and treatment plan, reference evidence-based practices and clinical guidelines. This demonstrates your commitment to providing the highest quality care and helps justify your treatment decisions.
- Collaborate with other providers: When appropriate, share relevant information from your progress notes with other healthcare providers involved in the child's care. This collaboration promotes a comprehensive approach to treatment.
Frequently Asked Questions (FAQ)
What is the purpose of SOAP Notes for Children and Adolescents?
They serve as a structured, comprehensive way to document therapy sessions with clients under the age of 18. They ensure that all relevant aspects of the session are recorded, including subjective and objective observations, assessment of the child or adolescent's progress, and the treatment plan moving forward.
How do SOAP Notes for Children and Adolescents differ from regular SOAP Notes?
While both follow the SOAP format (Subjective, Objective, Assessment, Plan), SOAP Notes for Children and Adolescents specifically address the unique needs and challenges of pediatric clients. They include information gathered from the child or adolescent, parents, caregivers, and other relevant sources, and document their progress, treatment goals, and necessary adjustments to the treatment plan.
What are the key components of a SOAP Note for Children and Adolescents?
- Subjective (S): The child or adolescent's personal experience, thoughts, feelings, and concerns shared by themselves or their parents or caregivers.
- Objective (O): Observable behaviors, appearance, affect, engagement, and significant non-verbal cues or interactions.
- Assessment (A): Evaluation of the session information, considering the child or adolescent's progress toward treatment goals, new insights, patterns, or concerns.
- Plan (P): Next steps in your client’s treatment, including changes to the treatment plan, homework assignments, referrals, and scheduling the next session.
How often should I write SOAP Notes for Children and Adolescents?
Write a progress note after each therapy session with a pediatric client. Doing so ensures that you capture all relevant information while it's still fresh in your mind and helps maintain a comprehensive record of the child or adolescent's progress over time.
Can SOAP Notes for Children and Adolescents be shared with other healthcare providers?
Yes, when appropriate and with the necessary consent, your notes can be shared with other healthcare providers involved in the child or adolescent’s care, such as pediatricians or school counselors. This collaboration supports a comprehensive approach to treatment and ensures that all providers are working together to support the child's well-being.
