DAP Notes Examples for Mental Health

DAP Notes are a popular type of psychotherapy note used to document therapy sessions and are stored as part of a patient’s official health record. DAP stands for: Data, Assessment & Plan. This format provides a simple and effective way to track client progress over time. DAP progress notes are brief, comprehensive, simple to create & modify if necessary, and easy to include in a patient’s electronic health record (EHR). Below, we’ll explore how to write them with a few simple DAP Notes examples for mental health professionals.

What Are DAP Notes?

There are many kinds of clinical notes, each with its own acronym—SOAP, BIRP, DARP, etc.—so how are DAP notes different? Let’s break this acronym down, letter by letter.

Data

The data section is where you will include everything you heard and saw during your therapy sessions. This information includes:

• Patient’s reasons for therapy
• Patient’s mental state
• Patient’s appearance (body language, cleanliness, etc.)
• Patient’s current reported symptoms
• Important life events that have happened since the previous session
• Any screening or testing results
• Any interventions (treatments) used in the therapy session
• Patient’s response to above interventions used in therapy session
• Patient’s behavior towards & level of participation in therapy

Remember, this section is purely for information—i.e, objective data—and should be as fact-based as possible. Much of this information will be self-reported by the patient, so use direct quotation whenever necessary. However, this section can also include your clinical observations, such as whether a client presents as irritated, anxious or increasingly distracted.

Assessment

In this section, you apply your clinical lens to the information in the previous section. This is your interpretation, a working hypothesis based on subjective analysis.

In the assessment section, you will attempt to answer:

• Is your patient committed to therapy?
• Is your patient making any progress?
• Is your patient at risk for self-harm or harming others?
• Is there a specific issue or diagnosis?
• Assessment of screening or testing results from previous section
• Assessment of patient’s response to interventions used

Remember to distinguish the application of clinical judgement from simply being judgmental. In addition to thoughts, feelings and ideas, you must include your rationale for all the above. Imagine how a colleague, another provider or even a lawyer might read this section. They should be able to clearly connect the logic and reason in your assessment to the data gathered above.

Plan

The plan section of the DAP Note refers to your plan for future treatment. This is not your overall treatment plan, but what you hope to accomplish and the actions you’d like your patient to take from session to session.

This could be “homework” assignments, like reaching out to a consequential person in their lives or keeping a journal that documents triggering experiences. Meanwhile, you may consult with your patient’s psychiatrist or primary care physician about starting a medication, changing the dose or switching to another medication.

This section lays out:

• The date of the next therapy session
• Any planned future interventions
• Your patient’s “homework” assignments
• Any follow-ups or consultations with other members of the patient’s care team
• Any changes to patient’s therapy goals & treatment plan

It’s important to note that, while this DAP Note section does not stand for your patient’s treatment plan, it may affect some part of it, or potentially change its direction.

While there are similarities between SOAP Notes (Subjective, Objective, Assessment Plan) and DAP Notes, there are some key differences. The most important difference between these note formats is that the subjective and objective fields of a SOAP Note are combined into the “Data” section of a DAP Note.

This can be helpful because, while objective information is easier to gather for healthcare providers in traditional medical settings, it is a bit tougher to define in behavioral health. Almost everything that clinicians hear from their patients qualifies as subjective information. They are unreliable narrators, essentially, because one can only speak from their own experience. It can be argued that the only objective information you have in a therapy session is the physical appearance of a patient and certain types of psychological assessments—which, arguably, are also subjective.

Of course, the SOAP format is still popular and effective for mental health professionals. However, the DAP format is potentially easier for a therapist to use because it does not require them to parse objective & subjective data; they simply include all relevant information as data. Synthesizing both forms of information in this way can lead to a more comprehensive evaluation of a patient’s condition and mental health.

DAP Note Creation Checklist

DAP notes are short and simple, but there are several things to keep in mind when compiling them. Some standard tips include:

Create a Template

DAP Notes are simple to make. You can, conceivably, create them yourself and upload them to your patient’s EHR. However, good mental health software should enable you to easily create HIPAA-compliant custom forms or case notes that are attached automatically to your patient’s EHR. A tool like this saves time, helps with organization and minimizes your workload.

Be Thorough & Succinct

To get your DAP Notes exactly right, you need to include only essential information that illustrates a clear point and do it quickly. Remember that DAP Notes are not your private notes; they are part of an EHR and can be read by many people.

Make it a DARP Note

DAP Notes can be easily modified according to your needs, and a popular way to modify the DAP Note is to add a patient Response section following the Assessment section. With this new section, a DARP Note is born.

Your client’s response to your assessment is traditionally noted in the Assessment field, but you might think it significant enough to have its own section. For instance, your patient may become very defensive at your observation that they’ve been purposely avoiding certain people or responsibilities, or that their drinking or recreational drug use has noticeably increased to the point of self-medicating. They may make elaborate excuses or shut down completely.

Adding this section is optional and based on your need and clinical discretion.

Write Notes Immediately After Your Session

You must be present during sessions; taking progress notes on your patient’s time won’t go over well. For the most accurate DAP Notes, you’ll need to write them immediately after your session has concluded. The longer you wait, the more accuracy and impartiality suffer. Make some time in your schedule for this, maybe 10–15 minutes. This can be difficult with a packed schedule. Mental health software, like Vagaro’s, has a scheduling feature that enables you to slot this time between appointments.

Write For Your Audience

This may sound like something out of the TV writer’s handbook, but it’s important to consider who may read your DAP Notes, and why. They may be used to decide something especially important about your patient, like a medication change. Or they may be referenced as part of a malpractice suit. Make sure the language you use is widely accessible, yet professional. Do not use slang or colloquialisms, unless quoting a patient directly. Always check your session notes for grammatical and spelling errors.

Keep Treatment Plan in Mind

DAP Notes—particularly the Plan section—should not be treated as a patient’s treatment plan; they should be guided by it. The treatments and interventions laid out in your DAP Notes should reflect the treatment goals outlined in the greater treatment plan.

DAP Notes Sample Template

Writing DAP notes is an exercise in accuracy and organization, but it doesn’t have to be complicated. Here are a few simple DAP Notes examples for patients presenting a few common mental health conditions:

DAP Notes Example: Depression

First Name: Sara Last Name: Williams

Date of Birth: xx/xx/xxxx Patient ID: 12345A

Data

• Patient arrived on time for second consecutive session
• Patient appears well-groomed and less lethargic, yet unfocused
• Patient notes that while sleep has improved since last session, negative thought spirals remain a problem
• The patient named work performance and the recent end of long-term relationship as sources of stress
• Used intervention to counter patient’s assessment of herself; patient became emotional but wanted to “push through it.”
• Patient did not report nor show any signs of being at risk for self-harm
• Discussed antidepressants, which patient was open to considering

Assessment

• Depressed mood
• Fluctuating self-esteem & opinion of herself
• History of depression, anxiety, bipolar disorder & substance abuse on both sides of patient’s family
• Patient has limited emotional support and “cannot talk to either parent” as they struggle (“poorly,” in patient’s words) with same issues
• Lacks reliable set of coping skills, as well as physically & mentally stimulating outlets

Plan

• Next session scheduled for Wednesday, April X, at 4:00 PM—one week from today
• Give psychiatric referral for medication evaluation
• Goal is for patient to become vitally absorbed in activities outside of herself—dance, Pilates, photography
• Gave assignment to keep a detailed log of negative thought spirals, which we will discuss in next session
• No major changes to the overall treatment plan

Clinician’s Name: Samuel Jones

Designation: Dr.

Signature:

Date: xx/xx/xxxx

DAP Notes Example: Anxiety

First Name: John Last Name: Martin

Date of Birth: xx/xx/xxxx Patient ID: 12345B

Data

• Patient reported difficulty sleeping for several weeks
• Racing thoughts a consistent issue for “a long time”
• Cites student debt, financial stressors and job stability as contributors
• While he “knows it’s unlikely,” patient fears losing his job, becoming financially unstable
• Wants to take a trip to Italy to visit extended family but fears he can’t afford it
• Probably can afford Italy trip, but fears spending “frivolously,” especially if he “loses his job”
• No evidence that the patient may lose his job; was recently promoted
• Is open to exploring anxiety medication

Assessment

• Anxious mood, catastrophizing scenarios about career, money and personal freedom
• Challenged patient’s thought process and suggested that his anxiety is impeding his “personal freedom”
• Patient is responsible and capable yet feels incapable of “rebounding” if unforeseen circumstances occur
• The patient’s family has a history of money troubles and lack of fiscal responsibility that affected him greatly as a child, shaping his relationship to finances
• Becomes overwhelmed with menial tasks, and even otherwise enjoyable activities, to the point that he sometimes cannot complete either
• Should respond well to a set structure for daily life

Plan

• Session scheduled for next week at same time
• We will work on patient’s view of himself and dealing with unknowns, as well as adding structure to his life
• Add structure by breaking down certain tasks into manageable steps for this week:
• Will update passport
• Research 3 different flights to Italy
• Check bank account for ways to cut expenses in order to feel more comfortable & secure in doing the things he wants to do
• Bring in findings
• If this is successful, we will continue to add structure to daily & weekly routines
• Will give psychiatric referral for medication evaluation

Clinician’s Name: Samantha Jones

Designation: Dr.

Signature:

Date: xx/xx/xxxx

——

DAP Notes and other forms of patient documentation do more than illustrate your competency as a clinician. They enable you to be more collaborative with patients and develop better clinical outcomes. They are evidence of your ability & clinical judgement and provide a record of all treatments used for insurance reimbursement purposes. Moreover, paired with the right forms creator, they save you a lot of time.

Vagaro’s HIPAA-compliant practice management software makes writing progress notes and creating other custom patient documentation easy. All notes are automatically stored to a patient’s profile for easy future access. Going paperless with EMR patient notes & forms is just one way that Vagaro can help you run your private practice more efficiently, help you put patients first & give you back some of your time. Taking better care starts with Vagaro. Sign up for your FREE 30-day trial and experience what it can do for your business.