Soapie Charting

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, nagaway 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 copatients 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.