Creating and maintaining a clients case notes

Running head: CASE NOTES 1
CASE NOTES 3

Case Notes for a Client Using the Signs and Symptoms, Topics of Discussion, Interventions, Progress and Plan, and Special Issues (STIPS) Format
Name
Institutional Affiliation
Case Notes for a Client Using the Signs and Symptoms, Topics of Discussion, Interventions, Progress and Plan, and Special Issues (STIPS) Format
Introduction
Creating and maintaining a clients case notes is a necessary practice that ensures an accurate account of the happenings at each session. According to Francis (2018), case notes support the counselors responsibility to the client by promoting his or her dignity and welfare because it is a record necessary for the clinical management of the clients case. There are different formats of making case notes such as Behavior Action Response- BAR, and Subjective, Objective, Assessment Plan- SOAP among others. The paper focuses on STIPS format
Clients Summary Case
The client is 26 year old African American male studying at TTR University. The client is pursuing an MBA program and resides near the university. The client was self referred to our counseling center where he reported that he experiences difficulties attending classes, has depressed mood and recently ended a romantic relationship with his long time girl friend. The client is also experiencing concentration problems, memory loss, weight loss without dieting, and insomnia. The problems worsened during the last two weeks prior to visiting the counseling center.
Case Notes using STIPS
Signs and Symptoms
The client attended the first session dressed in a long black jacket, wrinkled shirt, ball cap and tattered trousers. He had guarded facial expression although he was tearful, he appeared depressed. He reported that he continued experiencing memory and concentration problems, loss of pleasure, poor eating, social isolation, and intense fatigue.
Topics of Discussion
The intake assessment was reviewed before he was seen; some of the information where verified by him to help in proper diagnosis. He reported that when he was 20 he had a major depressive episode. The session focused on distress, poor concentration and feeling isolated.
Interventions
Rapport with the client was created through empathy and listening techniques; the counselling process was explained to him and his expectations highlighted. He agreed to take Beck Depression Inventory -11 in the course of the week.
Progress and Plan
There is little change observed in his behaviour; however, he appears confortable with the counselling session. We plan to assess his copping skills and strengths as we continue to discuss treatment goals.
Special Issues
The client denies any thinking of committing suicide. Given his previous history of a major depressive episode, he will be referred for a psychiatric evaluation before being given antidepressants.
References
Francis, P. C (2018). The Notes of Our Profession. Web. Accessed on 21/10/2020