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SOAP Notes

SUBJECTIVE
Sarah Smith is a 28 year old, married woman of 3 years, with a 6-month old
daughter. Patient reports her recent moods havent been happy. Complaints of
inability to leave the bed in the morning, emotions are easily triggered and personal
hygiene has been avoided. Shes been facing major problems with her career and
home life. Complains of an inability to live her social and work life as she once had
before having a child. There is also a confession of guilt for resenting her husband
and child, despite her past yearnings for motherhood. She expresses contempt
against her husband forcing her to move to an area that was so far out of her
normal pattern, especially within 3 months of the family addition. This is just one of
the many examples she states of how her husband tries to understand, but tends to
overlook the stress it causes her.

OBJECTIVE
Sarah showed up to the last 2 meetings wearing dirty sweatshirts and pajama
pants with stains on them. Her hair hadnt been brushed and she showed signs of
having cried just moments before. In the first 15 minutes of the session, she had
managed to start and stop crying, exclaiming to herself that she was supposed to
be grateful for her child. Her current state of mind is affecting her overall health.

ASSESSMENT
There is a chance Sarah is currently suffering from Post-Partum
Depression after her recent pregnancy. It is my impression that her mood
swings have been related to her overall neurochemistry, as well as the
various factors surrounding the recent changes that have happened. Sarahs
pre-child tendencies centered around autonomy and independence, and the
responsibility of human growth has left her with a sense of empty goals. If
she fails to introduce any changes in her daily habit, her condition may
worsen, and her mental health may fall even further.
PLAN
The immediate plan for Sarah is to introduce her to a therapist whose
focus centers new families and the problems they face. Her husband will
have to begin tending these sessions in both a paired, and individual
manner, as his level of communication has decreased due to his career, and
a therapist would provide the adequate room for him to develop an
understanding of both his relationship and his responsibility. I would
recommend Sarah develop new patterns and life goals which can allow her to
reach for new goals that accommodated for family lifestyles rather than
autonomous lifestyles. As for her career, discussing a part-time employment
option for her career may be a viable option, if her desire for a career were

strong. I would recommend and increase in overall exercise in order to


accommodate for any restlessness.