This is the fourth post in a series that highlights standardized formats for your clinical notes. The series began here.
A third format for clinical note taking is commonly known as BASIC SID. This is yet another mnemonic. The letters stand for Behavior, Affect, Sensation, Imagery, Cognition, Spiritual (and Religious), Interpersonal, and Drug (and Biology).
Behavior refers to what you see your client doing and not doing.
Affect refers to both your client’s mood and congruence with expressing those moods.
Sensation refers to your client’s awareness of his five senses and includes hallucinations, perceptual illusions, muscular tension or pain, excessive sensitivity to environmental stimuli, and what the client saw and heard.
Imagery related to your client’s past, present or future in any way includes dreams, fantasies, obsessions, flashbacks and responses to guided imagery.
Cognitive focuses on your client’s constructed meaning i.e. self talk, mental abilities, personal narrative, beliefs and mental schema.
Spiritual includes your client’s beliefs related to a Supreme Being, affiliation and practices with religious groups, religious resources, conscience and moral development, themes of guilt and forgiveness, creativity, and personal comfort related to ideas of spirituality.
Interpersonal references your client’s relationships with others, level of social skills, degree of acculturation, and any incidents of social injustices.
Drug and biological includes your client’s use of chemicals (both illegal and legal), medical compliance and concerns, and any incidents of delirium or dementia.
What I really like about a BASIC SID clinical note is that the acronym provides prompts to help me remember to focus on all areas relevant to my client’s progress.
Tomorrow I will talk to you about taking clinical notes using the Gillman HIPAA Progress Note.
Hi Tamara,
I’ve been reading many pages of your very helpful website. Thank You!
I’m wondering if you have a resource for “example” pages of the various types of notes. It always helps me to see a real life example (with obvious privacy considerations taken care of)
Thanks!
Hi, Ann! Thanks for reading my blog and taking the time to drop in to chat. I’m sorry though – I do not have sample pages of the various types of notes to share with you.That’s a great idea, though! I should put that on my to-do list! Feel free to keep checking back. Perhaps I’ll get that put together for you in the next couple of months!
In the mean time, where are you (geographically), Ann, and what is it you do?
It would be great to see examples!
I’m a recent graduate from the Clinical Mental Health program at Goddard College. I passed the NCE and now have my LPCA, so I’m provisional at last. I live in North Carolina. I’m 47, so I’ve come late to this professional life. I’ve been an unschooling mom to three kids for the past 20 years. I went back to school to finish my BA, then do my MA.
I’m in the process of figuring out what is next. I live semi rural so I will be creative in creating the kind of work I want to do. Also since I am older and still very involved with the lives of my children my standards are high about what type of work I will do.
I am interested and have training in childhood trauma and expressive/creative therapies.
My hope is to begin a small private practice in my barn. 🙂 I have a perfect room for an office and plenty of outdoor space for labyrinth walking and messy creative work.
It’s a daunting prospect so I’m researching. Your site has helped quite a bit! Thank you for that.
Oooohhhh, Ann! I’m so jealous! I live in Colorado now but lived for 10 years in Avery County, NC. You are making me so homesick! LOVE the idea of beginning your practice in your barn. Wish I was there to “play” with you. I’m sure we could collaborate on something! Art in the barn! That’s fabulous! Where in NC are you?
(And, thank you for letting me know you find my work to be helpful to you as you map out a plan for your own. That means everything to me!)
Well, you lived in a gorgeous area of NC! 🙂
I’m a Midwesterner who would like to live in Wisconsin as the heat is hard for me here. But, it is a beautiful area. We are an hour south of Asheville which is lovely. Asheville is so fun!
Come visit some time. The room I’m planning for my practice is our “company space”. It’s like a one room apt. 🙂
Colorado sounds nice too. My 18 yr old keeps wanting to go there. I guess the grass is always greener……? lol
“The grass is always greener . . . . ” It’s true! It’s true! Ann, I can’t wait to hear / see how you develop your “company space.” And, don’t be surprised if I call / email one day to say “Hey, Ann! I want to come to NC to host a little gathering to there to talk about practice-building or using social media to promote therapists’ projects. Got any space big enough to accomodate us?” I’m always looking for opportunities to do some training, host some conversations, meet some of my e-friends, and do a little traveling, too. Right now I’m in NJ doing just that. I was in California last month and will be in Nevada next month. Let me know if you see something that might be of interest. And, if / when you make it to Colorado, don’t forget to look me up! Always happy to connect in person!
In the mean time, thanks for hanging out with me online!
I’d love such a call/email! I’ve got the space! 🙂
I really want to find a way to host CE workshops and meet/greet events for networking here.
I am sort of rural but only and hour from Asheville, NC and Greenville, SC.
Keep in touch!
Hi Tamara,
This is my very first reply to any of my internet professional therapeutic contacts. If I was a client of yours, your very warm smile would initially catch my attention, and the therapeutic process would definitely begin on a positive note.
In this series of standardized formats for note-taking, you initially caught my attention with the “SOAP” method, that we used many years ago at the Downsview Rehabilitation Centre, of the Province of Ontario’s Workers’ Compensation Board, Toronto, Canada, which was closed a number of years ago. I was then in the Psychological Services Dept.
Presently, I can’t help but comment on your modification of Arnold Lazarus’s “BASIC ID” to “BASIC SID”, because, of course, my name is Sid.
After several years of semi-retirement, and then marrying my teenage sweetheart on Feb. 14, 2010, after not having seen each other for almost 50 years, give or take, I’m planning to start up a private practice, although, as you have no doubt calculated, I’m becoming rather “long in the tooth”, as they say. However, I feel I still have much to offer, including many years of experience, and that my involvement will assist in maintaining my longevity.
Thanks for your useful and entertaining information and, have a great weekend.
Sid Kimel.
Hello, Sid Kimel! And, welcome to Private Practice from the Inside Out! I, too, am “long in the tooth” and so are many of the folks you’ll be running in to here. Most are either (1) venturing out into private practice for the first time and looking for support in doing so or (2) they have been in private practice for a while but are wanting to expand their business into a new area.
I love your story of reconnecting with your sweetheart! What fabulous inspiration for love and retirement!
And, I can’t take credit for the modification of Lazarus’ BASIC ID. Someone else – smarter than me – modified it. I just liked it and decided to share it here. Either way, it’s a useful system for capturing what matters.
I’m happy to have your voice voice here, Sid, and am hoping you’ll show up here often – to share what you know and your challenges, too!