As a mental health professional, writing client notes can feel like a never-ending task, and realistically it is...
Ensuring we are compliant and following safety regulations means painstakingly documenting everything both inside and outside our sessions, and unfortunately, it's not something any practitioner can do.
To make this process slightly less painful, there are progress note templates that can streamline the process and ensure you get a comprehensive set of details down in the most efficient way. The only question left is which template we should use?
DAP or SOAP?
In this article, we'll run you through both so you can decide which option will suit your practice better…
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.
To help you, we've outlined each section of a DAP note in detail:
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.
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.
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.
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What are SOAP notes?
SOAP documentation is a powerful tool for simplifying clinical notes. It provides an efficient way to capture, store and interpret your client's information consistently over time. Spending too long capturing progress notes is a colossal waste of time and money for any healthcare business.
The SOAP notes for mental health help practitioners use their clinical reasoning to assess, diagnose, and treat patients utilizing the information presented. The SOAP note template structure acts as a checklist, enabling practitioners to capture the info consistently while also providing an index to retrieve historical information if required.
SOAP is an acronym that stands for subjective, objective, assessment, and plan. The elements of a SOAP note are:
Subjective (S): Focused on the client's experience and perceptions of symptoms, needs, and progress toward treatment goals.
Objective (O): Includes observable, objective data ("facts") regarding the client, like elements of a mental status exam or other screening tools, historical information, medications prescribed, x-rays results, or vital signs.
Assessment (A): Includes the clinician's assessment of the available subjective and objective information. The assessment summarizes the client's status and progress toward treatment plan goals.
Plan (P): Records the actions to be taken due to the clinician's assessment of the member's current status, such as assessments, follow‐up activities, referrals, and changes in the treatment.
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DAP notes vs. SOAP notes: What's the difference?
SOAP notes are considered the standard practice for practitioners following a standardized documentation method. However, both have some clear differences, including the following:
- The subjective and objective sections are separate - SOAP notes are more suited to medicine in general as opposed to mental health in particular. For example, a practitioner concerned with a client's physical health can make measurable objective observations such as weight or height and then, in the subjective, take the chance to note down comments from the client verbatim.
- There will be a greater volume of objective information, such as vital signs (e.g., heart rate, blood pressure) and other ostensive data as a medical doctor. The only objective information available in a session concerned with the mental state is the physical presentation and psychological assessment results.
Therefore many mental health professionals prefer the DAP note. Meaning they are not required to struggle to categorize information as objective or subjective, and simply include it all as data.
SOAP and DAP note templates
To help guarantee your clinical documentation is organized and consistent, here are downloadable templates (in both SOAP and DAP formats).
Feel free to have a look at each of them before deciding which format best suits your professional preferences.
How to write good SOAP and DAP notes
To ensure that your notes are high quality, there are some important tips that you should incorporate.
- Focus on your audience - Because SOAP and DAP notes are often used in consultation with other healthcare professionals, as well as viewed by the clients, it’s important that you maintain professionalism across all clinical notes.
- Keep it simple - Avoiding abbreviations, and using simplified language can prevent miscommunication across healthcare practitioners. This doesn’t mean that you need to dumb down your note entirely - but phrase them so the meaning is less likely to be misinterpreted, and others can pick up on exactly what you’re trying to say.
- Consider DARP instead of DAP - Sometimes practitioners expand their DAP notes by adding an ‘R’ response section, which can add additional insight when it comes to patient responses to assessments. If you want your notes to be more comprehensive, consider implementing these components for a more detailed summary.
- Be concise - While your notes should be comprehensive in nature, this doesn’t mean that they need to be pages long! You’re not writing an essay, and your clinical notes will shed greater insight if they cut to the chase in a more logical fashion.
- Implement automation - Automated tools are a great way to proofread, and edit your notes, as well as save you copious amounts of time. Using tools such as voice-to-text transcription, as well as grammar checkers, you can produce much more accurate notes in significantly less time.
- Sign entries - Although this may go without saying, make sure to always sign your entries in order to comply with accountability and security standards. Only authorized healthcare professionals should have access to creating healthcare notes, and in the case that the note needs to be used within a legal case, having signed entries is a good paper trail.
- Write legibly - If you’re handwriting notes, make sure that you take the time to incorporate clear handwriting that is easy for anyone to decipher. Doctor’s notes are notoriously known for illegibility issues, so make sure that you have clear notes!
Are DAP notes or SOAP notes more useful for therapists?
As a mental health professional, it can be difficult to consider an 'objective' observation as not subject to personal opinion. For example, if a practitioner was to say that their client appeared to be low in effect, they are unable to quantify that. The practitioner may note the client appears low in effect, and another practitioner in the same session may say they appear to be tired. For this reason, you may find merging the subjective and objective sections of client notes to be more accurate as they are both relatively subjective.
Ultimately both SOAP and DAP notes are entirely acceptable. The important thing is to remain consistent, systematic, and organized in your practice.