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Are you a mental health professional?
Are you looking for a way to streamline your process for creating progress notes?
Well, look no further than this article ☺️
We've created a guide to keeping mental health progress notes and giving you information about which template will work best in your practice setting.
Thousands of mental health practitioners use progress note templates such as DAP notes, and DAR notes to streamline keeping track of client interaction and ensure they get a comprehensive set of details down in the most efficient way, creating more time for client-facing hours.
If you're just around for the templates, check out some DAP notes templates here.
What are DAP notes?
DAP notes in mental health are a documentation methodology used frequently by mental health practitioners to track client progress and store as part of a client's official health record. DAP is an acronym for Data, Assessment, Plan. It's designed to assist practitioners in standardizing their documentation methods.
A DAP progress note template was designed similarly to the SOAP note, and the only difference is that it is more specific to mental health practitioners. The difference is that the subjective and objective data is not separated as often it can be challenging to differentiate between what you identify as either objective or subjective. For example, stating that a client appears to be low in effect cannot be quantified; in addition to this, an initial assessment may prove to be difficult as there may not be any data to compare this client's baseline. For this reason, it can be easier to combine both subjective and objective data within one section to avoid incongruent or incorrect documentation.
Each letter of the DAP acronym corresponds to a different section; we've outlined what you want to include here:
Subjective & Objective Observation
Collecting subjective information will involve asking questions and gathering data regarding how your client feels about their condition. Descriptions, observations, and thoughts on the client's current state give insight into their perception of themselves and their state. The next is objective, unlike subjective observation; this will require you as the practitioner to observe and comment on your client's condition. Often including comments on your client's appearance, mood, and affect.
Assessment
This section of the DAP note provides a working hypothesis by understanding your client's current state. It is helpful to include any other screening or assessment results to give the reader of the DAP a rich picture of the client and their presentation.
Plan
This section is relatively self-explanatory but does require several details to ensure you complete a comprehensive write-up for your client. Be sure to include any medication, therapy, and alternative treatments you want to include in their care plan. Goals are another valuable part of the DAP, not only for the client but also for other practitioners within the client's care team.
How do you write good DAP notes?
Writing good DAP notes can be tricky, so here are some of our top tips to make sure yours are up to scratch:
- Length is essential. While including details is necessary, try your best to keep your writing concise (no practitioner wants to spend half the day reading a DAP note).
- Know what you aim to achieve. Just as you set out goals for your clients, try to follow your instructions and desire to perform better in your day-to-day practice.
- Use different tools to your advantage. There are various tools you can access to improve the value and content of your DAP notes. These might include charts, diagrams, direct quotes from the client or care team.
- Consider turning it into a DARP note. In this instance, the 'R' stands for a response. They are allowing a section for the client to respond to the assessment.
What is the DAP assessment?
The assessment section of the DAP note provides a working hypothesis by understanding your client's current state. It is helpful to include any other screening or assessment results to give the reader of the DAP a rich picture of the client and their presentation. To complete a thorough assessment, you'll want to gather and document both subjective and objective data in the first section. It will involve collecting subjective information through asking questions and gathering data regarding how your client feels about their condition. Descriptions, observations, and thoughts on the client's current state give insight into their perception of themselves and their state. The next is objective, unlike subjective observation. This will require you as the practitioner to observe and comment on your client's condition. Often including comments on your client's appearance, mood, and affect.
What are DAR notes?
Nurses typically use Dar notes as a form of focus charting to record significant events or an acute change in the patient's condition that arises within the client's care. Like DAP, DAR progress notes are an acronym that stands for data, action, and response. DAR progress notes help nurses by providing a systematic template for each patient and their specific concerns and strengths to focus on the care provided. The first two sections of DAR notes are the same as DAP, so D stands for data, both subjective and objective. While A stands for assessment. The R is different and stands for response, slightly changed from the P for plan.
When should DAR notes be used?
To help guide you as to when to use DAR notes, we’ve collated a list of some situations that would benefit from their use for nurses. Sometimes it can be tricky to know what warrants DAR note usage - and you’ll be glad to know that for pretty much any circumstance, they significantly elevate the quality of your assessments.
Tracking patient progress - Whenever you meet with a patient and work with them overtime, DAR notes serve as excellent reference points for you to come back to. You can evaluate the health of a patient more holistically, and track their improvements across time, which makes for high-quality assessments.
First-time patients - DAR is highly effective at noting all critical details when it comes to assessing patient health and identifying areas that need improvement. When first meeting with patients, DAR can prove very beneficial in noting down all essential information to move forward productively in future appointments.
Targeting health - DAR is fantastic for assessing specific health concerns and issues, as it focuses on particular areas of interest. You can go into detail about a patient’s health concern and produce rich insights for more effective health treatments that directly address root causes.
What are the main elements of DAR notes?
There are some core components of DAR notes that allow you to touch on all critical patient aspects, without missing other crucial pieces of information. Specifically, the following elements are what comprise DAR notes, and enable them to produce unique health insight:
D for Data - The D section requires both objective and subjective information from your patient about their current health state and is used to formulate an effective treatment plan. This means that you must capture the patient’s experience in their words, which can be through verbatim quotes, as well as including measurable information. This includes any data including test and lab results, vital signs, and other assessment forms that are quantifiable and not arbitrary. It is neutral and only consists of professional health judgments.
A for Action - This section synthesizes the data insights you’ve gathered, and uses them to provide a solid direction and next steps for the patient to improve their health condition. This may entail prescribing medication, forwarding it to other healthcare professionals, or requesting specific treatment.
R for Response - As the final section, this area focuses on the patient’s response to the previous section. For example, this includes how a patient reacted to their medication, whether they are following due course, or whether further improvements are needed.
DAP Notes vs. DAR Notes: What's the difference?
The main difference between DAP and DAR notes is that the DAR note is more specific to nurses. Although there is no F (focus) in the DAR acronym, it is essential not to forget the note's focus, whether it's stated or not. The focus of the note is the subject or purpose for creating the documentation; one reason might be something like the nursing diagnosis. Events that might require documentation include admission, discharge, or a change in the patient's condition, such as acute pain or a shift in the patient's pathophysiology or pathophysiology.
Another difference is the R instead of the D, R for response refers to how the patient responded to the nursing care plan carried out. This may not be documented for some time following the execution of the plan of care as the care plan may extend over minutes, hours, or even days. While slightly different, both DAP and DAR notes obtain the same benefits; it's just that one is more specific to nurses that may be dealing in physiological ailments in addition to/ or psychological ones. As a professional, which template you use is up to you!
DAP Note Examples
Example #1
Data: The client’s depressive symptoms have improved in getting “7 hours of sleep per night”, however, she still often feels "low." She expresses concern over the lack of joy she receives from hiking still, and that she “doesn’t enjoy the thought of it like I used to.”
Assessment: Client has major depressive disorder with a family history. She demonstrates anhedonia, but improved sleeping from 7 hours per night, whereas this was 3 previously.
Plan: Client will continue taking 40 milligrams of sertraline once per day. If her symptoms do not improve in two weeks, the clinician will consider titrating the dose up to 50 mg. Client will be seen with me next Friday at 11:30, November 3rd.
Example #2
Data: Client had their fourth session of CBT to address moderate depression. The client appeared fatigued and spoke slowly. The client said that they had struggled to find the motivation to get out of bed, stating that “I thought I was doing better, but this week I just couldn’t find the strength to move.” The client scored a 15 on the BDI-II in the moderate range and failed to meet goal of going for a walk every day for 30 minutes.
Assessment: Trouble sleeping and motivation to do normal everyday activities. Score has worsened on the BDI-II in comparison to last week’s session with a score of 12, which suggests that interventions need to increase. Low risk for suicide.
Plan: The next session is Wednesday September 24. Patient has been given a higher dose of Prozac, coping strategies, and referral is a considered option.
Example #3
Data: Cravings for heroin are strong, with client identifying he thinks about it “15 times a day”. He does, however, feel comfortable speaking up in group sessions, stating “I feel more open with my team.” He states this his relationship with his wife has improved, as they attend secondary therapy together.
Assessment: His cravings have reduced from 30+ times a day to around 15, and has improved in his confidence about his addiction. He is more confident in group settings and is improving social relations when this was difficult last week.
Plan: Continue attending group sessions and secondary therapy with wife. Client is scheduled for a session with me next Thursday Oct 1.
DAR Note Examples
Example #1
Focus: Pain
Data: "Continuous ache in the right arm," pain 8/10. Tramadol 30mg was given at 0900 and has stated a noticeable reduction in pain to 6/10.
Action: Pain relief seemed to make improvements, however, the client still feels pain.
Response: The patient has been provided Oxycodone 6mg and Tylenol 1000mg in addition to breathing exercises.
Example #2
Focus: Transfer following procedure
Data: Received patient transfer post-procedure - thoracentesis.
VS: HR 80, BP 160/90, O2 sat 95%. The patient was sleeping on their side.
Action: Administered Morphine 2mg IV and repositioned to the unaffected right side.
Response: The patient remained to doze throughout, with no stirs. Comfortable breathing.
Example #3
Focus: Patient dizzy
Data: Patient feels disoriented, with face pale. Perspiration on the forehead, and eyes are glassy. Patient states “my vision is kinda blotchy.”
Action: Patient is laid on the bed, back against the mattress. Given damp cloth, with sugar candy.
Response: Patient’s color is coming back into their face, and seems more responsive. Can see straight without hazy vision.
How to use Carepatron to write DAP notes and DAR notes
Carepatron is one of the world’s leading practice management platforms when it comes to healthcare, and is trusted by 10,000+ healthcare professionals. You can effectively write DAP and DAR notes through its sophisticated features that are sure to elevate the quality of your practice. You can utilize aspects, such as the following:
Store all notes - With HIPAA-compliant services, you can store all your clinical DAR and DAP notes and access them from one place, without having to worry about data or security breaches. You can access patient information without having to search extensively, and store a variety of different types of files and supporting documents (including images, letters, PDFs, and more!).
Compose documents - Obviously, with Carepatron, you can create DAP and DAR notes from the platform without having to go elsewhere. It makes things simple and convenient, and with our library of healthcare templates, you can ensure you’re crafting notes of the highest quality
Voice transcription - Using voice-to-text services, you can draft notes in no time, with the software picking up on every word you say, and jotting it down seamlessly. Automation can save you time and energy, as well as increase the accuracy of your progress notes with no fuss.
Should you use DAP notes or DAR notes for your medical practice?
As a professional, your discipline and your current role will dictate whether DAR or DAP notes are a more appropriate choice. There’s no exact right or wrong answer here, and it’s important to trust your professional health opinion, and whatever best suits your health demands.
Have a look at this link to check out some tips for note preparation.
So, which template should you use? Well, that one is up to you! Go well ☺️
Further reading:
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