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    SOAPIE Charting

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    pircano
    The client reports being easily awakened at night due to noise from quarreling co-patients which reminds him of a past traumatic incident with police. He appears anxious with limited eye contact. He is able to describe events but anxious and stammers, having difficulty describing voices he hears. In a second session, the client reports hearing voices when drinking but no longer due to medication compliance. He speaks irrelevantly and with flight of ideas, showing anxiety about sharing hallucinations or voices heard. Rapport was established and medication initiated in both sessions.

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    SOAPIE Charting

    Uploaded by

    pircano
    12K views2 pages
    The client reports being easily awakened at night due to noise from quarreling co-patients which reminds him of a past traumatic incident with police. He appears anxious with limited eye contact. He is able to describe events but anxious and stammers, having difficulty describing voices he hears. In a second session, the client reports hearing voices when drinking but no longer due to medication compliance. He speaks irrelevantly and with flight of ideas, showing anxiety about sharing hallucinations or voices heard. Rapport was established and medication initiated in both sessions.

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    psychiatric soapie

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    The client reports being easily awakened at night due to noise from quarreling co-patients which reminds him of a past traumatic incident with police. He appears anxious with limited eye contact. He is able to describe events but anxious and stammers, having difficulty describing voices he hears. In a second session, the client reports hearing voices when drinking but no longer due to medication compliance. He speaks irrelevantly and with flight of ideas, showing anxiety about sharing hallucinations or voices heard. Rapport was established and medication initiated in both sessions.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    12K views2 pages

    SOAPIE Charting

    Uploaded by

    pircano
    The client reports being easily awakened at night due to noise from quarreling co-patients which reminds him of a past traumatic incident with police. He appears anxious with limited eye contact. He is able to describe events but anxious and stammers, having difficulty describing voices he hears. In a second session, the client reports hearing voices when drinking but no longer due to medication compliance. He speaks irrelevantly and with flight of ideas, showing anxiety about sharing hallucinations or voices heard. Rapport was established and medication initiated in both sessions.

    Copyright:

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    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 2

    SOAPIE Charting #1

    January 12, 2009

    S: Client states that he couldn’t sleep and can easily be awakened early in the morning at
    about 2AM. He stated that when the co-patients quarrel he viewed it as a distraction and
    that he is afraid of noisy environment because he reminisces the incident where he is too
    afraid of the policemen. “Ang mag-asawa na iyan, si Barry at ang kanyang asawa, nag-
    away kagabi. Para bang nagsasagutan. Eh ang inga-ingay nila. Hindi ako makatulog.
    Parang napapaisip tuloy ako noong nasa bahay pa ako na parang natatakot na baka
    pasukin kami ng mga pulis.”

    O: Appears anxious, limited eye contact during sharing of feelings and giving a brief
    story about how he felt during hours of sleep. He is easily distracted and selective
    inattention for he always involves what he sees in his conversation such as involving co-
    patients and give comment on them and laughs.

    A: Client is able to describe the happenings during the night. He is anxious and stammers
    in his speech evident for being afraid and unwillingness to tell the fact. He isn’t able to
    describe the voices he hears most of the time.

    P/I:

    1. Established rapport to client.


    2. Established self-awareness, and oriented to time, person and place.
    3. Approached client and sat in a thirty degree angle together with the client.
    4. Identified which stressors contribute to maladaptive behavior.
    5. Encouraged verbalization of feelings as tolerated and as the client is willing to
    share.
    6. Initiated medications as ordered.
    7. Encouraged to attend remotivation and culminating activity.

    E: The client is able to share feelings unresistingly and shows appropriate affect during
    conversation.
    SOAPIE Charting #2

    January 12, 2009

    S: Client stated that he was drinking alcohol. Each time he drinks he can hear voices
    around him but doesn’t believe on the words the voices are telling him. The words aren’t
    clear and he feels afraid sometimes when the voices involves the policemen or about the
    raid that had happened in their place. During the conversation with the client, he
    suggested that the voices were gone because he stated that he has not been taking alcohol
    and that he is undergoing medication. He added some information irrelevant to the topic.
    “Sa ngayon wala naman akong naririnig na mga boses boses na iyan. Mas nakakatulog
    ako ngayon kahit walang inuman kaya lang kung minsan medyo madali akong magising
    sa konting ingay ingay na prang ‘tulog manok’ ba. Gusto ko nga maging manok nalang
    ako para hindi na ako makakainom ng alcohol at para hindi na ako makapagtulog-manok.
    (laughs).

    O: Appears anxious and speaks irrelevant answers evident for having flight of ideas.

    A: Client is able to describe feelings about drinking alcohol but showed irrelevant queries
    that suggest anxiety of giving out information about his hallucinations or of hearing
    voices around him.

    P/I:

    8. Established rapport to client.


    9. Established self-awareness, and oriented to time, person and place.
    10. Approached client and sat in a thirty degree angle together with the client.
    11. Identified which stressors contribute to maladaptive behavior.
    12. Encouraged verbalization of feelings as tolerated and as the client is willing to
    share.
    13. Initiated medications as ordered.
    14. Encouraged to attend remotivation and culminating activity.

    E: The client is able to share feelings unresistingly and shows appropriate affect during
    conversation.

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