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…
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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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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SOAP notes are considered the standard practice for practitioners following a standardized documentation method. The difference here is that within SOAP notes, 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 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.
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 affect, they are unable to quantify that. The practitioner may note the client appears low in affect, 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.