| S |
Subjective
- Information relevant to what the client reveals in the session.
- Client history and background.
- Example: The client reported changes in mood and low energy level.
|
| O |
Objective
- Factual information (symptoms, client's appearance, orientation, behaviours, mood or affect).
- According to Google AI and reddit, this is as good a place as any to document interventions.
|
| A |
Assessment
- Your clinical impressions and interpretation of the objective and subjective information.
- Example: Depressed mood and depression.
|
| P |
Plan
- What do you, as the clinician, plan to do with the client at the next session?
- Example: Give psychiatric referral.
|