Look at the PowerPoint that was uploaded and follow the direction of the other uploaded documents to complete assignment. The Power Point case study is the client Various Social Work documentation styles are used to capture client-social work interactions such as SOAP notes, DAP notes, and BIRP notes.Upload three Progress Note documentation styles below (1 SOAP, 1 DAP, and 1 BIRP note to complete the progress note assignment of an interaction you have had with a current client from your field placement. The notes should be completed in one Word document and submission with the heading above it indicating the Note style. The BIRP note checklist should be used to evaluate if you have captured all required components of the note but the BIRP note itself should be written in the same heading and format style as a DAP note as indicated by the headings below, DO NOT SUBMIT THE BIRP NOTE CHECKLIST as the Note.SOAP notesSubjective, Objective, Assessment, Plan (S.O.A.P.):

Subjective- document the client’s own observations.

Objective- what does provider perceive?

Assessment- write about client progress

Plan- document changes, additions, and revisions to care plan
BIRP notesBehavior, Intervention, Response, Plan (B.I.R.P):B-Behavior includes Social work Observation and client statementsI-Intervention social worker used to address goals, objectives, observations, and clients statements.R-Response of client to intervention, Treatment plan goals and objectivesP-Plan that documents next steps for client.DAP notesDescription/Data, Assessment, Plan (D.A.P): D – Data – a factual description of the session. It generally comprises 2/3 of the body of the note and includes information about the general content and process of the session.A – Assessment – an evaluation by the therapist of current status and progress toward meeting treatment goals. P – Plan – Statements about what will happen next.B.I.R.P. Progress Note Checklist
B Behavior
Counselor observation, client statements
Check if
1. Subjective data about the client—what are the clients observations, thoughts,
direct quotes?
2. Objective data about the client—what does the counselor observe during the
session (affect, mood, appearance)?
I Intervention
Counselor’s methods used to address goals and objectives, observations, client statements
1. What goals and objectives were addressed this session?
2. Was homework reviewed?
R Response
Client’s response to the intervention, progress made toward Tx Plan goals and objectives
1. What is the client’s current response to the clinician’s intervention in the session?
2. Client’s progress attending to goals and objectives outside of the session?
P Plan
Document what is going to happen next
1. What in the Tx Plan needs revision?
2. What is the clinician going to do next?
3. What is the next session date?
General Checklist
1. Does the note connect to the client’s individualized treatment plan?
2. Are client strengths/limitations in achieving goals noted and considered?
3. Is the note dated, signed and legible?
4. Is the client name and/or identifier included on each page?
5. Has referral and collateral information been documented?
6. Does the note reflect changes in client status (eg. GAF, measures of functioning)?
7. Are all abbreviations standardized and consistent?
8. Did counselor/supervisor sign note?
9. Would someone not familiar with this case be able to read this note and
understand exactly what has occurred in treatment?
10. Are any non-routine calls, missed sessions, or professional consultations regarding
this case documented?
Check if
CLIENT NAME: _______________________
DATE _______________
SESSION GOAL: ______________________________________________________
ASSESSMENT: _______________________________________________________
PLAN: _______________________________________________________________
SOCIAL WORKER Signature _____________________________________________
DAP Progress Notes
D – Data – a factual description of the session. It generally comprises 2/3 of the body of
the note and includes the following information about the general content and process
of the session:

Subjective data about the client – what are his/her thoughts, activities,
observations, desires, complaints, and self-reported problems, needs, limitations,
strengths, and successes?

Subjective data about the therapist’s activities and use of self – what is the
therapist doing in response to treatment goals/objectives and client needs (e.g.,
therapeutic techniques being employed)?

Objective data about the client – what was the therapist observing during the
session about the client’s affect, mood, and appearance?

If therapeutic tasks, homework and/or behavior plans are a part of treatment,
include comments about reviewing those items and tweaking assignments.

Detail activities that reflect a clear association to the goals and objectives noted
in the client’s treatment plan.

Document any referrals you make.
A – Assessment – an evaluation by the therapist of current status and progress toward
meeting treatment goals. It generally includes information about:

The therapist’s current working hypotheses about dynamics and diagnoses.

The therapist’s description of client’s progress in response to the treatment.

Perceived client insights and motivation to change.
P – Plan – statements about what will happen next. It includes two (or three) things:

When and what is the next session? (e.g., we will continue weekly individual
therapy next week). If there will be a gap due to vacation, holiday, etc., note that.

What is the plan for the next session? (e.g., we will continue to focus on anger
management, or we will include spouse and address communication issues).

If new information becomes available, progress (or the lack thereof) occurs,
additional problems arise, or the simple passage of time means a treatment plan
update is needed, note that too, as a prompt to do the update next session.
Other guidelines for DAP notes:

Write legibly and use only black ink.

Spell correctly and use full, grammatically correct sentences.

Be careful with abbreviations (must be standardized and consistent).

Content must be written in a way that even someone unfamiliar with the case can
easily understand what occurred.

Client name, number, date, time, and other top-of-the-page data elements must
be completed.

Sign every note.

Do a note for each missed session (client cancellations / no shows).
S: “I wanted to talk to my kids about how guilty I feel about my drinking.”
O: Tearful at times; gazed down and fidgeted with shirt buttons
A: Consumer has gained awareness in how drinking behavior has embarrassed and
hurt his teenage children. He expresses intense feelings related to his drinking and
appears to assume responsibility for his past behaviors.
P: Completed Tx Plan Goal #1, Obj 1. Continue with Goal #1, Obj 2, in next session.
Sally Jones, CAC
D = Describe
A = Assess
P = Plan
D = Data
A = Assess
P = Plan
OTHER: _______________________________________________
*Note other documentation formats used in agency/regional area
OTHER: _______________________________________________
*Note other documentation formats used in agency/regional area
Treatment Planning M.A.T.R.S.:
Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful
Workshop 4 – Handout 2
S. O. A. P. NOTE
S = Subjective or summary statement by the client. Usually, this is a direct quote. The
statement chosen should capture the theme of the session.
1. If adding your own explanatory information, place within brackets [ ] to make it clear
that it is not a direct quote.
♦ Example of session theme: “When he raises his voice, I just . . . what do I do? . . .
Yes, I’ll talk more in group.”
2. If client refers to someone else’s name, indicate that other person by initials. This
makes it clear that the client is the focus, not the person the client is talking about. It
also guards against any breeches in confidentiality. This is especially true when a client
refers to another client.
♦ Example of client using someone else’s name: “She really made me mad . . . You
think I should make an appointment to talk to her? I don’t like dealing with this stuff
[case worker S.P.].
3. If the client didn’t attend the session or doesn’t speak at all, use a dash on the “S” line.
♦ Example: S: –O = Objective data or information that matches the subjective statement. Descriptions
may include body language and affect.
♦ Example: 20 minutes late to group session, slouched in chair, head down, later
expressed interest in topic.
A = Assessment of the situation, the session, and the client, regardless of how obvious it
might be based on the subjective and/or objective statements.
♦ Example: Needs support in dealing with scheduled appointments and taking
responsibility for being on time to group.
♦ Example: Needs referral to mental health specialist for mental health assessment.
♦ Example: Beginning to own responsibility for consequences related to drug use.
P = Plan for future clinical work. Should reflect interventions specified in treatment plan
including homework assignments. Reflect follow-up needed or completed.
♦ Example: Begin to wear a watch and increase awareness of daily schedule.
♦ Example: Complete Tx Plan Goal #1, Objective 1.
♦ Example: Consider mental health evaluation referral.
♦ Example: Contact divorce support group and discuss schedule with counselor at
next session.
Adapted from work by Larry T. Mark and presented by Donna Wapner, Diablo Valley College. Handout
included in materials produced by the Pacific Southwest Addiction Technology Transfer Center, 1999.
Treatment Planning M.A.T.R.S.:
Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful
Workshop 4 – Handout 3
Client’s profile

The patient is a 39-year old African American woman who
is low income.

She graduated from college five years ago.

The client is divorced with three children ages 2, 4, 6 two
boys and a girl. Client does not have a job (was fired two
months ago).

She has been divorced for six months now with the exhusband currently living with the children.
History of presenting problem

The client has been depressed after experiencing a
horrible divorce six months ago.

The loss of her only source of income has worsened her
situation considering that she comes from a low-income

The fact that the husband took away her kids is also
making her feel depressed.

She has resorted to the use of alcohol to cope since she
became divorced.
Assessment of the problem(s) and
client’s strengths.

The main issue facing the client is alcoholism. She has
been over drinking a lot considering the recent events she
is experiencing in her life.

The other problem is the depression caused by the loss of
her job and children.

The lost of her job is making it hard for the client to
settle her bills.
Assessment of the problem(s) and
client’s strengths.

Lastly, the client is also struggling to cope with divorce
which has resulted to the loss of her children.

Some of the client’s strength include the ability to sustain
herself despite the high poverty levels.

Determined to do better for her family

The client also adapts easily meaning that the
intervention program may workout effectively.
A plan for working with the client and
the problem(s)

The intervention plan would involve both short-time and long time

Asking open-ended questions would provide room for the client to
express herself thus helping address the issues she is facing.

The plan would also involve working with relatives and close friends
of the client for better results.

The main problem is that the client may find it hard to stay away
from the alcohol in the entire period.

Also, failing to see her children may make it hard for her to
Intervention(s) to be used with the

The intervention would rely mostly on strengths-based interventions.

I would utilize mezzo practices were the family, friends, and the
relatives of the client will be involved in the intervention process.

It would be hard for the client to stop taking alcohol on her own
hence the need to involve friends and relatives.

The involved parties will be required to keep a close look at the

Doing so would empower the client to reduce alcohol intake and
concentrate in getting a new job and children back.
Evaluation of the process

The client would be required to reduce alcohol
consumption by half within the first three weeks.

Relatives would help in sorting the financial issues for the
client during that period.

I would try to reach out to the husband to allow the client
to see her children at least twice a week gradually more.
Evaluation of the process

Doing so would help a lot in relieving the stress of not
seeing her children for that long.

The achievements made by the client would be weighed
at the end of every week.

The client would also fill a questionnaire to determine the
steps made in the recovery process.
A plan for follow-up

The client try to establish a functional relationship with the exhusband.

Client will continue Parenting class to help relationship with the

Client continue to attend AAA meetings and a sponsor.

The court would thus be involved to grant the client access to her

Community support group and the various government programs
would be used to support the client to get food, shelter, and other
form of support.

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