How to Write DAP Notes (With Examples)
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There are many different formats and structures available for psychotherapy and counseling progress notes. One of those formats is DAP notes. Bear in mind that the requirements for documentation vary by clinician, clientele, and a number of other factors. Simply put, there’s no single right way to do documentation, but your documentation format and content should be aligned to your specific practice and needs.
What is a DAP note?
A DAP note is one of the most popular and current ways to write a psychotherapy or progress note. So what is a DAP note? DAP stands for Data, Assessment, and Plan, and is used by counselors and psychotherapists everywhere. DAP notes provide a standardized way to document your sessions and follow the D-A-P format every time. This note structure also helps clinicians develop documentation that is both brief and complete. Done well, each section should make good logical sense based on the information in previous sections.
What's the difference between SOAP notes and DAP notes?
The main difference between SOAP notes and DAP notes is the last section. If you’re familiar with the SOAP note structure, DAP notes are very similar. DAP notes take the Subjective and Objective sections of a SOAP note and combine them into a single section: data.
How long should a DAP note be?
There’s no rule for exactly how long DAP notes should be. The note length depends on a lot of factors, and it’ll vary based on your individual client and the treatment plan you come up with together.
As a guideline though, DAP notes can be shorter when the client is making routine, expected progress. This can be toward treatment goals, if they present low risk for suicide or other violence, and if there are no changes to their diagnosis or treatment. Longer notes typically are the result of a client not making expected progress, if their symptoms change, if they present heightened risk, or when changes appear necessary to the diagnosis or treatment plan.
How to write a DAP note
When you write a DAP note, it will always follow the same format no matter who your client is. However, the content that’s included in each section of the DAP note can vary based on a number of factors. We’ll go through what each section of a DAP note should include, and how they would be applied with an example.
D – Data
This section is where you add data from your counseling or psychotherapy session. This could include:
- Reason for the visit
- Client presentation/appearance
- Client mental status
- Client reports of current symptoms or important events since the last session
- Results of screening or other measures
- Interventions applied in session
- Client responses to interventions applied
It’s important to note that this section should be limited to information, not interpretation. Speak factually, and if appropriate, use direct quotes.
A – Assessment
This section is where you take the data from the first section and apply your clinical judgment to it. This could include:
- How the client is progressing
- How the client’s status relates to their treatment goals
- How the client responded
- Changes to the client’s diagnosis
Every note typically includes some evaluation of risk in this section, to ensure that potential indicators of suicide or other forms of risk have been assessed and the clinician has responded appropriately.
All conclusions in this section should be clearly supported by the data in the first part of the note. In fact, when the Data section is done well, the Assessment section will read to clinicians as obvious conclusions based on that Data.
P – Plan
Given the observed data and your interpretation of it, where does treatment go from here? This section could include:
- The date, time, and location of the next scheduled session
- Homework assigned to the client
- Referrals provided to the client
- Consultation or other third-party contact planned by the clinician
- Changes to the treatment plan based on the client’s progress so far
- Additional steps related to the treatment that the client or clinician is expected to take
DAP notes therapy example
We’ve created DAP note example to help give each section more context.
DAP note example for depression
D- Data
Client reported on time for a third session of CBT to address symptoms of depression. Client was well-groomed and fully oriented. The client reported feeling “a little bit better here and there” since the last session, and noted that they have had an easier time getting to sleep at night. Client also noted recent financial stressors. The client scored a 14 on the BDI-II, scoring in the moderate range. In session, challenged the client’s automatic negative thoughts around their work performance and relationship functioning. Client reported feeling increasingly agitated but understanding that this was “part of the work.” When offered the opportunity to stop the intervention, the client asked instead to continue. Client neither displayed nor reported any other current risk factors for suicide or violence.
A – Assessment
Client reports of reduced sleep symptoms and improved mood, and their improved score on the BDI-II relative to initial assessment, suggest improvement toward treatment goal of reducing depressive symptoms below diagnostic threshold. Client responded well overall to interventions, and appears to be well-motivated to continue. Client appears to demonstrate low risk level for suicide or violence; the safety plan established with the client at the first session remains in effect.
P – Plan
Our next session is scheduled for Thursday, March 17 at 10:00 am via telehealth. Assigned the client a thought record chart to specifically log instances of automatic negative thoughts regarding relationship functioning. Provided the client with referrals to three potential financial advisors to address reported recent financial stressors. No changes indicated to the treatment plan. Client to follow steps of established safety plan if symptoms significantly worsen prior to the next scheduled session.
How to use DAP notes with your EHR
Now that you have an understanding of the question “what is a dap note,” it’s time to explore how to put them to use in your practice. To use DAP notes with your EHR, you can either upload a template, or follow the note structure within your software. A top-rated EHR will have a dedicated section for notes and documentation, as well as easy-to-use templates that are built right into the platform.
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