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Monday, 23 January 2017

How to write up your client notes


Having never thought very much about this topic in a formal way before, I have been asked for advice on it several times recently. Whether this is serendipity, fate or just plain old coincidence I thought it would make the subject of a good blog.

It may surprise you to know that there are formal guidelines for recording your client sessions if you choose to use them. These are, I think, more familiar to counsellors than hypnotherapists, but they certainly have something going for them in that they standardise your notes taking and allow you to focus on the most important elements of the session.

There are a number of these guidelines but the one I have chosen to look at here is called SOAP. This is, of course, an acronym, meaning that each letter stands as a reminder for something you need to cover. In short these are:

  • Subjective - subjective information is about perception: how someone experiences things in their own mind, it's based on feelings or opinions rather than facts. The subjective part of your notes is often the longest, it includes the case history, along with how the client has been feeling this since your last meeting, how well they feel they are progressing. For example, the client may say they are feeling generally more positive.
     
  • Objective - objective information is based on facts: it's measurable and observable and does not take account of feelings or opinions. This section might include factual information the client gives you, or your own factual observations. For example, you might record examples of language that demonstrate their new positivity.
     
  • Assessment comes next - this is your professional opinion about how well the client is doing, comparing their progress with your therapy plan and their goals to check that things are going in the right direction.
     
  • Planning is the final stage - a look ahead including any actions to be taken by either you or the client to move things forward. I’d include a note about what techniques or scripts you have used in this part.

Here’s an example of SOAP notes based on a fictitious client.

  • S - Mabel reports that she is finding it easier to stick to her diet and make healthy choices about exercise. She feels proud of herself for the progress she's made, and is starting to like what she sees in the mirror. There was a setback when her husband tried to persuade her to share a bar of chocolate with him. She got very upset and he didn’t seem to understand why. She felt he had broken his promise to be supportive and wonders if he really understands how important it is to her to lose weight.
  • O - Mabel went out for a meal with friends and chose to eat salad and fruit, when they all had heavy meals. She is looking slimmer, she has lost 14lbs since therapy began and dropped a dress size. She has a new hair style this week and increased confidence is indicated by her making more eye contact than previously. When talking about her husband her body language changed, she slumped in the chair and appeared tearful.
  • A - Mabel is progressing well for both weight loss goals, as she has reduced her portions and undertaken regular exercise.
  • P - Continue with original therapy plan, agreed another target of being more resilient when tempted to break her diet by others, especially her husband.
    Hypnotherapy in this session: Elman induction, peaceful place, control room metaphor to reinforce changes, protective bubble for resilience.
    Mabel is to continue to listen to my weight control CD daily, I will email her the URL of my blog containing resilience tips.

It would be easy enough to have a form in your records which recorded each session in the same format and using this type of format helps to keep your sessions focussed and on track.

So, do you use a specific format to write up your notes? Or are you game to try this one? Let me know how it goes.


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Author: is an experienced hypnotherapist and hypnotherapy trainer. She is the author of Their Worlds, Your Words and has co-written the Hypnotherapy Handbook, both of which are available from Amazon. Find out more about Debbie's services on
Yorkshire Hypnotherapy Training - multi accredited hypnotherapy practitioner training, taster days and foundation levels.
CPD Expert - accredited CPD courses (on line and workshops options), expert supervision

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