Accil desk Manual

Documentation

Consumer contact notes should be written in plain English, so that a lay reader can understand. Each consumer contact note should contain four elements, summarized in the acronym SOAP: Subjective, Objective, Assessment, and Plan, as follows:

1. 
   Subjective refers to the consumer’s current situation, need, symptoms, and other aspects of his/her present experience, preferably using his/her own words (and/or those of a significant other) as circumstances permit.
   
2. 
   Objective refers, commonly, to numerical data supplied by other sources (e.g., age, weight, etc.) and by the staff person’s direct observations of the consumer (e.g., “angry”) and of the situation (e.g., “was accompanied by her husband”). Inferences, reactions, and other information that goes beyond these sources do not belong here.
   
3. 
   Assessment refers to the staff person’s sense of what is happening, consistent with his/her qualifications. Staff licensed to render psychiatric diagnoses should enter those diagnoses in accordance with applicable laws and other guidelines. Staff should not render diagnoses or other assessments for which they lack formal qualifications. Statements of personal reaction or emotion are not assessments.
   
4. 
   Plan refers to the steps that the staff person takes, or intends to take, in response to the assessment and/or the needs/goals expressed by the consumer.
   

Where did you meet? Who was present? What did you discuss? What was accomplished? What are the next steps?	Use terms such as: “Consumer reports …” “Consumer seems…” “I suggested…”
Subjects to be especially careful with: Information specific to a disability Jobs, “under the table” jobs, job loss Income and assets Illegal activities

Consumers have the right to read their file at any time. Consumer contact notes should not say things that are not true, not relevant, or not consistent with either the SOAP guidelines (above) or the specific requirements of the individual CIL. Frankness is important, but is not to be confused with unkindness. Highly personal information should be requested and recorded in a consumer contact note only if it is important for purposes of the service being requested by, considered for, or provided to the consumer.

• 
  Make a diagnosis (unless licensed to do so)
  
• 
  Be judgmental
  
• 
  Record extremely personal information
  
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  Include information about other consumers