Baby

Dr. Lawrence Weed (2011),
the creator of the SOAP method of
note taking.

Clinical Note Taking

“Baby” from the album For You (1977)

Clinical note taking is an important part of the counseling process. It is a tool that the counselor uses to ensure that the therapeutic process is moving in a logical and progressive way. There are many ways to take clinical notes however the most common way is the SOAP (subjective, objective, assessment and plan) method. In the subjective section a counselor focus on reporting the reason for why their client came in to see them. You do not interpret their words you simply report a summary of what is said. In the objective portion the counselor reports what they observed during the session. This includes nonverbal and verbal communication (physical appearance, rate of speech, mood, etc.). The assessment part is used for the counselor to gauge if the client is progressing towards their therapeutic goal(s) or not. The last portion is where the planning for future sessions and where any homework given to the client is recorded. So, Baby, what are we gonna do? We are going to use the song “Baby” to show what this method of note taking looks like   during a counseling session. Ready? Let's go.

Baby, what are we gonna do?

I barely have enough money for two
Subjective. This is a song about Prince singing about his regrets about getting a girl pregnant (he was 17 years of age at the time). Let's assume that Prince in this song is getting therapy to work through his feelings of future fatherhood. Furthermore let's imagine that the above lyrics were spoken during the session. In the objective session a counselor might record: “The client communicated their trepidation about the financial demands of fatherhood and his lack of means to care for the child. This concern keeps him up at night. This is subjective because there is no way for the counselor to verify this, they have to subjectively believe what the client is saying. Notice there was no judgment or rationalization of what was said only what was said.

I never would've thought that this would happen
To a very careful man like me
Objective. In this segment of the note the counselor records what they observe. For this situation they might state: “The client sat in a sloughed position the entire session. He hair was uncombed and his shirt was covered in stains. He cried when he talked about how careful he was using contraception.” Again there is no interpretation of what is seen. No psychoanalysis of the crying, just a report of them.

But baby, pretty baby, we're gonna work it out.

Assessment. The counseling process is a partnership. A counselor should never decide what is best for a client. They should always partner with them. The client is an expert on being them, the counselor is an expert in helping them become better at being them. That is why the assessment component is so crucial. It allows both parties to collaborate and create a plan that will be beneficial to the client. In this section if the client said the above lyric the counselor would be inclined to believe that the client is making steps to being okay with becoming a father. Whatever interventions that were used in past sessions are creating progress to the goal the client wanted to work towards.

Baby, baby, baby
It's you, said it's you, I truly adore
Baby, baby, we're gonna work it out
I hope our baby has eyes just like yours

Plan. At this point in the session the client has moved to a place where they have decided to make the relationship with the mother of the child work. He is almost rapturous about becoming a father. Any homework or activities would be given in order to help facilitate the client being more comfortable about being a parent; therefore, a counselor might suggest the following activity: “Client agreed to talk with his girlfriend about his concerns about becoming a father including but not limited to the financial stress and the contraception concerns.” Although he has decided that this is something he is willing to do his doubts more than likely haven't gone away. Having the parents of this baby talk together early on about the stresses of parenthood will create a habit of them going to each other to deal with stress instead of other people. One last thing about clinical notes, they are absolutely confidential. The client of course can request to see them at any given time. The only other time someone else will see the notes is if they are subpoenaed by the courts and that is not an easy thing. Warrants and other legal documents have to be furnished before they are released. So if you are curious to what your counselor is writing about you, next time request them so you can see.