SOCIAL WORK SOAP NOTE

Client: [Name]
Date of birth or ID: [Identifier]
Date of contact: [Date, start and end time]
Setting: [Clinic, hospital unit, home, phone, or video]
Social worker: [Name, credentials]
Reason for contact: [Referral source and question, or the reason for this contact]
Present: [Client and others, with their role or relationship]

SUBJECTIVE
Client's concerns: [What the client says is happening, in their words]
Stressors: [Health, family, housing, money, work, legal, or other]
Coping and supports: [How the client is coping, and who helps]
Goals: [What the client wants help with first]

OBJECTIVE
Observations: [Appearance, affect, behavior, engagement]
Screening results: [Tools used, such as a food insecurity, depression, or distress screen, with results]
Collateral information: [From family, the care team, or records, with the source]
Current resources: [Services, benefits, and supports already in place]

ASSESSMENT
Psychosocial summary: [How the stressors, strengths, and supports fit together]
Needs: [Practical and emotional needs, in order of priority]
Strengths: [Client and family strengths to build on]
Barriers: [What makes it hard to meet the needs or follow the care plan]
Risk: [Safety concerns screened, and the level of concern]

PLAN
Referrals: [Program or service, and status: made, pending, or declined]
Interventions: [Counseling, education, advocacy, or coordination planned]
Client tasks: [What the client agreed to do, and by when]
Social worker tasks: [What you will do, and by when]
Follow-up: [Date, type of contact, and what will be reviewed]

Signed: [Social worker name, credentials, date and time]