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 meticulously documenting everything that happens within and outside our sessions.
Although many clinicians (including myself) will tell you, it's their least favorite part of their role. Still, we know we need to continue doing it for the safety of our clients and our practice. Therefore, the motivation to ensure we engage in best practices is two-fold.
DAP notes have provided me with a guide to organize and streamline the information I incorporate into my notes. I want to share some information to help you do the same.
This Article Contains:
What is a DAP note?
What information is in a DAP note?
Our recommendations for DAP note templates
But what about SOAP notes?
Tips for writing DAP notes
DAP notes 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 note helps to ensure that you as a practitioner consider all the subjective and objective information to make the best assessment and consequential decisions for your client. DAP is a standardized documentation method. You need to ensure you include all the relevant aspects of the DAP within your write-up. To help you, we've listed the things to remember below:
Information is from the client's verbal report of how they are feeling. 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.
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. As an objective observer, you will want to have observations from several different senses. These may include being able to smell or see something worth noting in the client's progress notes.
This section of the DAP note provides a working hypothesis by understanding your client's current state. It is helpful here 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.
Adding the 'R'
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.
I have always found having access to an example or template of what I am trying to create incredibly helpful. For me, it takes away the initial phase of writing a report where I struggle to wrap my head around the entire document and means I can read one section and use it to create a comprehensive and concise document. Here are some of the templates I've used in the past:
This site has 28 different templates that provide you with examples of several DAP notes ranging from 300 to 2000 words and the option to download a blank template (for those like myself who struggle with structure in word). I would highly recommend reading some of these if you are new to the DAP note methodology to get a good idea of the tone and length you think is most appropriate for your setting.
Like Template Lab, Sample Templates will provide you with several templates, with and without exemplar content. They also have links to exemplars of SOAP notes and other forms of progress notes so that you can compare and contrast these layouts and find what is best for your practice.
SOAP notes could be 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.
As a mental health professional, I find it difficult to consider my 'objective' observations as not subject to my opinion. For example, if I was to say that my client appeared to be low in affect, I am unable to quantify that. I 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, I find merging the subjective and objective sections of my 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.
Click here to see some more of our recommended DAP note templates!