Anna Black: SOAP Notes Subjective: Anna feels that she is a bad wife, and feels some guilt over her husband’s decision to leave her. She also expresses anger at him for leaving. She feels a general sense of hopelessness. She has felt suicidal, has a plan to commit suicide, and seems to suffer from low self-esteem. Objective: Anna has not been sleeping, and has suffered from a substantial weight loss. Her libido is lower than usual, and she does not have the usual level of energy.
She is having difficulty getting herself together: she does not take time or effort on her appearance. She does not make eye contact and often breaks down into emotional crying. Assessment: Anna feels that life is not worth living anymore. While she is able to answer questions, she does not show affect, and sometimes answers questions with
...“I don’t know”. Ruminates often about failed marriage, and the part she played in this. Plan: Due to her suicidal thoughts, and the fact that she has communicated a plan, Anna will stay overnight in the hospital for observation.
Anna is open to discussing the idea of starting anti-depressive medication with a medical doctor or psychiatrist. Anna will return to counseling on a weekly basis to discuss her feelings of low self esteem and her depressive symptoms. Anna has been encouraged to confide in a close friend, with the goal of not feeling so alone in the hours away from counseling. Ethical Principle: Nonmaleficence. This counselor has a responsibility to do no harm in assisting Anna Black with her current mental issues.
In making detailed notes, this counselor is clearly attempting to outline the problem
(and their causes) that Anna is currently experiencing. If this counselor had not kept records about Anna’s situation and suicidal ideation, Anna may not have received the help she needed. If this counselor is a crisis-based hospital professional, it is possible that a variety of medical professionals will have contact with Anna before she is released from the hospital. Keeping good notes will help all of these professionals work together in helping Anna get better.
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