11 tips for writing DAP progress notes examples & templates (2024)

Katherine Ellison
Katherine Ellison
Share

Progress notes… They aren't the highlight of most mental health practitioners' days. But we've got to do them right! 

Fortunately, templates such as DAP exist that mean we can stay compliant and efficient! 

In this article, we'll provide you with a detailed outline of a DAP note, what you'll want to include in each section (yes, DAP is another handy dandy acronym 🤪), and 5 of our best tips for writing DAP notes. 

Buckle in!

Click here to view on YouTube

What are DAP notes?

A DAP progress note template was designed similarly to the SOAP note; the only difference is that it is more specific to mental health practitioners. In a DAP note, the subjective and objective data is not separated, as it can often be challenging to differentiate between what you identify as either objective or subjective. For example, stating that a client appears to have a restricted affect is not able to be quantified; in addition, 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. Additionally, DAP provides a standardized documentation method. By including all the relevant aspects of the DAP within your write-up, you’ll create documentation that is easily accessible, facilitating better clinical outcomes.

How long should DAP notes be?

It’s fairly difficult to give an exact length for how long a DAP note should be. The information that you include is highly dependent on your interaction with the patient and the details that you need to document. As a sort of rough guide, aim for 1-2 pages. You should be wanting to keep your DAP notes as concise as possible - however, this doesn’t mean skipping over important information. If your patient is making routine progress and their condition hasn’t had any significant changes, then your DAP note should be relatively short. In comparison, if your patient has recently experienced a decline in their health or if their treatment plan isn’t progressing, then it is likely the DAP note will be slightly longer. 

To help you visualize what the length of a DAP note should be, we’ve included a range of different examples. It’s important to remember that every practitioner will have their own method of documentation, so as long as you’re covering all the right information, you should be fine!

DAP documentation method

Learning how to write DAP notes is fairly simple. You'll want to incorporate each of these three sections chronologically, making sure to be as concise and informative as possible. Here is an outline of these sections and what needs to be included in each: 

Data

Within the D or data section of the note, you'll want to acquire as much subjective and objective data as possible. Within the mental health sector, this might mean gathering a significant amount of subjective information with congruent objective observations supporting what the client is reporting with no need to separate the two. 

Subjective observation 

Information is from the client's verbal report of how they are feeling. This may include: 

  • Client’s report of their current health status 
  • Quotes from the client 
  • Descriptions, observations, and thoughts on the client's current state

Objective observation 

Unlike subjective observation, this will require you as the practitioner to observe and comment on your client's condition. This often includes:

  • Reason for the visit
  • Comments on the client's appearance, mood, and affect
  • Interventions used during the session 
  • Client responses 

Assessment

The A or 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. Information included in the assessment section may include:

  • The client’s progress
  • How the client has responded to treatment so far
  • Changes to the client’s diagnosis 
  • Achievement of treatment goals

Plan

After gathering all the relevant data and making a professional assessment calling attention to the needs of each client, a plan needs to be formulated. This section is especially important as it ensures that other practitioners within the care team and the client can agree to and be informed of the plan of action. The plan needs to have the following information:

  • Date, time and location of next session
  • Specific goals for client to achieve between sessions
  • Referrals given to the client
  • Any changes to the current treatment plan
DAP note app

Ten tips for writing effective DAP progress notes

It can take a bit of practice to perfect your DAP notes and ensure you’re writing them efficiently and effectively. We have consolidated some of the top tips here to help you on your journey: 

1. Keep it simple

Length is essential – As the purpose of the DAP note is to assist you in writing a comprehensive assessment of the client, you may end up with a lengthy note. While including details is important, try your best to keep your writing concise (no practitioner wants to spend half the day reading a DAP note). Initially, you may find it difficult to know what data is essential to include and what can happily be left out without any consequence to the reader. A good idea can be to bullet point and provide diagrams or charts when necessary to ensure the reader can digest the information without any chance of confusion or miscommunication. 

2. Understand what outcome you want from the DAP progress notes

Know what you aim to achieve – just as you set out goals for your clients, try to follow your instructions and aim to perform better in your day-to-day practice. It could mean keeping 'the ideal' DAP note in front of you and striving to improve your writing ability clearly and concisely. In this instance, reviewing some different DAP note examples can be helpful and finding out what you think will provide the most value to your clients and workmates. We have identified some really helpful DAP note examples here to help you out. 

3. Use different tools to your advantage

There are several different 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, and using examples and templates to help you on your journey to creating the ideal progress note. If you're reading this article, you're already halfway there… Don't feel like you need to be a DAP note wizard from the start. At the outset, it can be better to be less concise and ensure you are compliant with including all the relevant information and then work on reducing down the content as you work out the core aspects of the note to include. 

4. Consider turning it into a DARP note

Some practitioners make DARP notes. In this instance, the 'R' stands for a response. They are allowing a section for the client to respond to the assessment. It's a beneficial tool in looking at the anticipated compliance and effectiveness of the assessment and treatment plan and can be a really good idea if you want to complete a more comprehensive DAP note. In an initial assessment, a longer and more detailed summary may require a response section. In this instance, you may want to use DARP instead of DAP. 

5. Understand who your audience is and what information is useful to them

Keep the audience in mind: DAP notes are written to be read by other practitioners in or outside the client's care team, other professionals involved, or the client themselves. Therefore, it is essential to keep the tone of your DAP notes professional. 

Think about what information you're including, the language you're using, and the reason behind each thing you include. What terminology will be the most useful and provide the most value to each group of people that are going to be digesting the information? 

6. Write in a timely manner 

We understand how hard it can be to stay on top of documentation, particularly if you see a lot of patients. Nevertheless, in order for your DAP notes to be as effective as possible, you should be writing them immediately after each session. This will help to guarantee that the information you include accurately reflects the patient’s condition, which in turn will lead to better communication and coordination of care. 

7. Professionalism 

DAP notes are not only shared between different healthcare providers, but they can also be used in legal settings. They should be professional documents that objectively outline a patient’s current health condition. This means you should avoid using abbreviations (that aren’t universally understood), medical jargon and judgemental language. Every statement that you make about the patient needs to be backed up by proof - this could be an example of the patient’s behavior or an unbiased observation that you have made.

8. Use the correct error procedure 

Everyone makes mistakes now and again. While this is fine, you need to ensure you follow the correct procedure. Errors need to have a single line crossed through them, and you also need to sign and date these. This ensures transparency, and also allows the reader to identify who made the error, when it was made, and the appropriate correction. 

9. Details

Although it is a good idea to keep your DAP notes as concise as possible, you should never skip over details. The information that is included within a progress note has a massive role to play in the coordination of care and clinical outcomes of a patient, so ensuring you double (and triple) check the details is an absolute essential. Additionally, you should ensure you are using the correct tense, pronouns, spelling, dates and time. 

10. Know what a perfect DAP note looks like 

The best way to improve your DAP notes is to have an idea in your mind of what the perfect note looks like. Although every practitioner will have their own preferences for writing progress notes, have a look at online examples or ask your colleagues about their methods. Having this knowledge will help guide your own documentation process and ensure you are holding yourself to a high standard and continuously looking for ways to improve.

Example of DAP progress notes

To help you visualize what the format of a DAP note looks like, we’ve included some useful examples.

Example 1

Data: John said that he was “feeling better” since last week. He reports sleeping at least 6 hours every night. John appeared attentive and his body language was alert. He has been compliant with anxiety medication yet says while his anxiety symptoms have been reduced, they are still presenting. He is struggling to reach out to family and friends and is experiencing feelings of isolation. 

Assessment: John is reacting well to the anxiety medication. He shows increased levels of concentration and improved eating and sleeping schedules. Session focused on finding ways to access social support. John shows reasonable improvement since last session. 

Plan: John will continue to have weekly sessions. He has a goal to contact a close friend and speak to his brother on the phone. Continue to work on swapping negative self-talk with positive self-talk.

Example 2

Data: Lily said “I feel bad everyday. Even getting out of bed is hard.” She replied in 1 or 2 word sentences to my questions and struggled to hold a conversation. Her body language was unsettled.

Assessment: Lily appeared to be reserved and withdrawn during the session. She could engage when she was asked direct questions. She has expressed concerns about relapsing. 

Plan: Lily is to continue her weekly sessions. She has an appointment with her psychiatrist to discuss medication. Treatment plan may be adapted depending on progress over next week. Low risk of suicide. 

Example 3

Data: Chris said he has felt more motivated recently. He is enjoying work and has started socializing regularly.  Chris was energetic and engaged during the session. 

Assessment: Chris is compliant with his medication. He exhibits improved engagement in his personal and professional life. 

Plan: Chris to continue fortnightly sessions. Medication to stay in place.

Example 4

Data: Susie spoke about her lack of interest in her work and personal life. She said she finds it “hard to feel excited”. She was attentive during the session and vocalized her desire to find a “solution” to how she is feeling.
Assessment: Susie is exhibiting mild symptoms of depression. Her desire to address these feelings demonstrates a self-awareness. 

Plan: Weekly sessions to continue. Susie has a goal to reach out to one of her closest friends and tell them how she has been feeling. She is going to take a day off work and complete “self-care” activities. 

Example 5

Data: Michael has been clean for 5 weeks. He reports feeling more energetic and engaged in his professional and personal life. He is still struggling with cravings. 

Assessment: Michael was engaged and attentive during the session. He was communicative and open about how he is feeling. Michael is learning to address the anger he feels towards his parents. 

Plan: Michael will continue weekly sessions. He has an additional group therapy scheduled for 1/10/2022. 

Example 6

Data: Sally says her depressive symptoms have improved. She is getting at least 6 hours of sleep every night and is forming regular eating habits. She expresses concern over her lack of enthusiasm for socializing, saying it makes her feel “low”.  

Assessment: Sally has moderate depressive symptoms. She exhibits self-awareness and was attentive during the session. Symptoms have improved since the previous session. 

Plan: Sally to continue taking prescribed Sertraline. Her goal over the next week is to go for 2 30-minute walks. Sessions to continue weekly. 

Example 7 

Data: James says he feels better than he has all year. He is “sleeping, eating and exercising well”. James has been seeing his friends regularly and is able to communicate his emotional needs to his partner. James was alert, attentive and had a positive disposition during the session. 

Assessment: James continues to show improvement. He is able to participate in everyday activities and maintain healthy relationships. 

Plan: Sessions to change from weekly to monthly. Will assess client’s progress at next sessions and determine whether medication dosage can be reduced. 

Example 8 

Data: Lisa’s cravings for heroin have reduced but they are still present “around 3-4 times a day”. Lisa was communicative and attentive during the session and she presented herself neatly dressed and groomed. She has started part-time work as a retail assistant and says this is “a good distraction”. 

Assessment: Lisa has found ways to manage her cravings. She attends regular support meetings and is able to discuss her emotions more freely. Her social and conversational skills have improved. 

Plan: Lisa to continue weekly sessions. She is going to increase her work hours from 15-20 per week. 

Example 9

Data: Client expressed deep feelings of grief about the death of her mother. She finds it difficult to “do everyday things like cook and eat”. She is scheduled to return to work next week and she feels “anxious” but is also “excited for normalcy”. Client says she has a good support system and speaks openly to her partner about her grief. 

Assessment: Client shows slight improvement. She was attentive during the session and able to discuss her emotions. She is continuing to work on grief coping mechanisms. No suicide risk.  

Plan: Client scheduled for a session next week on 4/10/2022. Will reassess suitability of returning to work and discuss reducing her hours. 

Example 10 

Data: Pete said he has been feeling “much better” since his last session. He has been exercising 3-4 times a week and says this helps keep him busy during his unemployment. He has had 2 job interviews in the past 2 weeks and is “excited” about these opportunities. 

Assessment: Pete has found effective coping mechanisms to manage his unemployment. His feelings of low self-worth have reduced. Pete has been replacing negative self-talk with positive self-talk and is open about his emotions. 

Plan: Change from weekly sessions to fortnightly sessions. Next session is on 09/18/2022. Pete is to continue practicing positive self-talk and exercising regularly.

Useful DAP notes templates for mental health practitioners

Fortunately, there are many resources available to help you get your documentation in order. If you are looking for helpful DAP note templates, then you’ve come to the right place. 

DAP Progress Note Template PDF
  • Downloadable Rutgers University DAP note: It outlines the different sections and what information you need to include. The prompts should help guide you through the process and ensure your notes are accurate and concise.
  • Sample DAP notes: These provide templates as well as example DAP notes so you can be sure your documentation is accurate. 

Although these templates are extremely useful, it’s important to keep in mind that every practitioner has their own preferences. You may want to utilize the formatting techniques of the templates and then edit them to suit your style.

How can therapists avoid these common DAP notes mistakes?

With the amount of work that therapists are required to complete, it’s no wonder that mistakes sometimes happen. Here is a list of some of the most common mistakes and how they can be avoided, so you can keep imperfections to a minimum. 

  • No evidence: Quite often therapists will write a statement that has no supporting evidence. Every time you state anything about a patient’s behavior or health status, you need to be able to provide some sort of objective reasoning. 
  • Repetition: You want to avoid repeating the same information you’ve included in each of your sections. Have a look over the DAP format and take note of the specific differences between each component. 
  • Overly wordy: Concise is key. When you review your DAP notes, cut back on language that seems unnecessary or overly wordy. Every sentence should be brief, to-the-point and intrinsic to the patient’s progress. 
  • Illegibility: You would be surprised by how many therapists have illegible handwriting! In order to ensure your notes can be adequately read, you’ll either need to work on your writing skills, or (and we recommend this option) use an online progress note platform.

Using a HIPAA compliant software to write DAP Notes

One of the best ways to streamline your documentation process without compromising on quality is through the use of HIPAA compliant software. These platforms have been designed to improve the effectiveness of your notes, whilst simultaneously saving you both money and time. Carepatron’s leading software is integrated with a range of different tools that will help you improve your DAP notes, including:

  • Create your notes: The system allows therapists to create, write, store and access progress notes all from the one site. Documentation is made significantly easier, and you no longer have to worry about messy handwriting or spelling mistakes. Additionally, you’ll have access to a wide range of templates, guaranteeing consistency across your documentation. 
  • Voice transcription: Voice transcription software is the leading time-saver when it comes to writing progress notes! The system picks up on every word you say and transposes it effortlessly to the page. What more could you want?
  • HIPAA-compliance: Of course, compliance is of utmost importance. Carepatron’s platform takes patient privacy very seriously, and you will be able to create, store and access your documentation from an extremely secure place.

What should be included in DAP notes?

DAP notes are relatively self-explanatory when it comes to what to include; data( both subjective and objective), so what you can gather anecdotally from each client and what you might observe with your senses, i.e., what you see, smell, and hear within a session. Analysis: Use your professional capabilities to deduce what the client is presenting with and their needs concerning this presentation. Finally, provide a plan of action or plan of care as to how you will go about addressing these needs you have identified. If required, you also need to include a section corresponding to the response in a more comprehensive or initial assessment or progress note. 

Ultimately, what's included in the DAP note is dictated by what is required of you as a mental health professional. Therefore, it is important to remain professional and formal within your note keeping and remember that your practice ability is reflected in this documentation.

DAP note app

Related Articles

Right ArrowRight Arrow

How to Start a Counseling Session With a Client

Learn essential steps for initiating a counseling session effectively with clients. Our blog guides you through the process. Start your first sessions with confidence!

Joshua Napilay
Joshua Napilay
5min read

Effective Therapy Icebreakers to Foster Connection

Learn about therapy icebreakers to make your sessions smooth and engaging.

Telita Montales
Telita Montales
6min read

Counseling CPT codes for private practitioners

Familiarize yourself with the most commonly used CPT codes for counselors. Equipping yourself with this knowledge will allow you to streamline the coding process and receive accurate reimbursements at a faster rate.

Katherine Ellison
Katherine Ellison
6min read

Depression worksheets for teenagers (Examples)

Managing depression for teenage clients can be complex. Here is a comprehensive overview of some of the tools you can use to help teenagers cope with their symptoms of depression, including examples of various worksheets.

Ashleigh Knowles
Ashleigh Knowles
6min read

Why Are ICD and CPT Codes Important for Private Practitioners? (A Complete Guide)

Understanding how medical coding works is an essential aspect of working in healthcare. Here is a complete guide to both ICD and CPT codes so your practice can perfect its coding process.

Ashleigh Knowles
Ashleigh Knowles
6min read

CPT Codes for Family Therapy Billing

Check out our guide to CPT codes for Family Therapy Billing, so you can improve the efficiency of your medical billing process and receive accurate reimbursement at a much faster rate.

Katherine Ellison
Katherine Ellison
7min read

CPT codes for psychological testing and evaluation

Familiarize yourself with the commonly used CPT codes for pyschological testing and evaluation so you can ensure you are maintaining compliance and staying on top of your billing.

Ashleigh Knowles
Ashleigh Knowles
6min read

Difference between CPT and HCPCS

Understanding the difference between CPT and HCPCS codes will allow you to optimize your coding process much more efficiently. Check out our guide and dive into the similarities and differences between these types of codes.

Jamie Frew
Jamie Frew
5min read

Top ICD-10 Codes for Speech Therapy (2024)

Here are 10 of the most commonly used ICD-10 Codes for Speech Therapy, so you can ensure your practice maintains its compliance and delivers accurate care services to patients in need.

Jamie Frew
Jamie Frew
7min read

Using the Right ICD Code for Autism

Having a good grasp of ICD codes will allow your practice to improve its compliance processes and ensure it receives accurate reimbursement. Here are some useful tips for accurately using ICD codes to diagnose Autism Spectrum Disorder.

Jamie Frew
Jamie Frew
7min read

A guide to CPT codes and how to use them

CPT codes are an essential aspect of classifying medical procedures in order to receive reimbursement. Check out this how-to guide and become an expert on CPT codes in no time.

Jamie Frew
Jamie Frew
7min read

Top ICD 10 Codes for Anxiety in 2023

Having a good understanding of commonly used ICD 10 codes will help your practice receive reimbursement in a timely manner. Find out what the most commonly used codes for anxiety are in 2023, and improve the efficiency of your medical billing and coding process.

Jamie Frew
Jamie Frew
7min read

10 coping skills worksheets for children (Examples)

Check out these 10 coping skills worksheets and help your young clients develop the skills to overcome whatever challenges they may be facing. These tasks are relevant, engaging, and most importantly, effective.

Jamie Frew
Jamie Frew
5min read

11 fun and engaging group activities for self care

Here are 11 fun and interesting group self-care activities that will leave you feeling refreshed and re-energized. From taking a yoga class together to hosting a game night, these activities will help you take care of yourself.

Jamie Frew
Jamie Frew
6min read

11 CBT Group Therapy Activity Ideas With Examples

Discover 11 creative and engaging CBT group therapy activity ideas with examples to help your clients build coping skills and improve their mental health.

Jamie Frew
Jamie Frew
6min read

20 ICD Codes for Mental Health in 2023

Here are 20 of the most commonly used ICD codes in the mental health sector in 2023. Having a good understanding of these codes will improve your medical billing and coding processes, enabling your practice to receive reimbursement at a much faster rate.

Jamie Frew
Jamie Frew
7min read

Top examples of group therapy game ideas

Check out some of the most effective group therapy game ideas, and help guide your clients toward their desired clinical outcomes using fun, engaging, and meaningful intervention strategies.

Jamie Frew
Jamie Frew
6min read

11 Engaging Ideas For Counseling Group Therapy

Discover effective and engaging ideas for your counseling group therapy sessions. Enhance your facilitation and improve outcomes for your clients. Read now.

Jamie Frew
Jamie Frew
8min read

Join 10,000+ teams using Carepatron to be more productive

One app for all your healthcare work