GHC HS 204 Writing Case Notes
What are four things good case notes do? - correct answer
Represent the client's situation; provide a record of client care; enable an action to
be taken based on their review; and can be used in court, in school, by social
agencies, and by insurance companies
To whom is documentation critical? - correct answer Clients
and family members; health care providers; employers and managed care
companies; and licensing and accreditation agencies
What are the three types of case notes? - correct answer
SOAP, DART, DAP
What does SOAP stand for? - correct answer Subjective,
objective, assessment, plan
What does DART stand for? - correct answer Description,
assessment, response, treatment
What does DAP stand for? - correct answer Description,
assessment, plan
In SOAP, what is subjective? - correct answer A summary of
important subjective statements and reports from the client; this provides
information on the subjective feelings and thoughts and reports of the client
In SOAP, what is objective? - correct answer A report of the
clinician's objective observation of client's behaviors and is usually in the form of a
mental status exam; not your interpretation of what you think it means; it should be
factual, concise, and professional
In SOAP, what is assessment? - correct answer Your
assessment of what is going on with the client; statements in this section are
