May 12, 2021 Each note should tell a story about your patient, and your subjective portion should set the stage. Try to open your note with feedback from the patient about what is and isn’t working about their therapy sessions and home exercise program. For example, you can say any of the following to get your note started. ♦ Example: Needs support in dealing with scheduled appointments and taking responsibility for being on time to group. ♦ Example: Needs referral to mental health specialist for mental health assessment. ♦ Example: Beginning to own responsibility for consequences related to drug use. P = Plan for future clinical work.
Data, Assessment, Plan. These are the fundamental building blocks of the DAP note. While they serve the same purpose as a SOAP note, DAP is a slightly different format. What you choose is entirely up to personal preference. This article should help you understand the basics of DAP notes and how to use them in your behavioral health practice.
What is a DAP note?
A DAP note is a method of documentation used by health care providers, social workers and similar professionals. While SOAP is a more popular format in medicine, the Data, Assessment, Plan paradigm is potentially more appropriate for behavioral health.
The Basics of DAP
- Data — this section includes observable and identifiable behaviors and traits. This section answers the question “What did I see during the session?”
- Assessment — this is about the meaning of the data. This includes clinical findings. Essentially, it answers the question, “What does the data mean?”
- Plan — this wouldn’t be a complete treatment plan, that would be on another document. (See our other article Writing Great Mental Health Treatment Plans for more detail on treatment plans.) The Plan section in a DAP note is where you answer the question, “What will I do in light of the Assessment.”
Some practitioners add “Response” to the Assessment section (i.e. DARP note,) however, this is really just an extension of the assessment. This would be where you would record the client’s response to the assessment. It’s a helpful mental tool for you to expand on the Assessment section; use it if you want. In mental health treatment especially, the client’s response can be valuable information as their response determines the effectiveness of any plan you might make.
SOAP or DAP? Which is better for mental health?
SOAP has traditionally been the “industry standard” for clinical notes. This is a result of the influence of the medical profession. While behavioral health, specifically non-psychiatric behavioral health treatment, is “health care,” counseling and therapy doesn’t have the benefit of the same sorts of diagnostic data as does medicine.
In a SOAP note, the Subjective section is where you record subjective feelings (obviously enough.) The problem with behavioral health is that much of your session is inherently subjective. Meaning, it’s difficult to take the “temperature” of a therapy client — a temperature is an indisputable fact, while, “appears to be falling asleep,” could be considered subjective.
What Is A Darp Note
Essentially, the problem with the Objective section is that many of the things you are recording aren’t quantifiable. Can you measure the degree of which a patient “appears to be falling asleep?” Can you compare that to another patient who is also “appearing to fall asleep?” It’s pretty hard and, unless you’re measuring vital signs and perhaps brainwaves during a session, ultimately, that observation is mostly subjective, however in a behavioral health SOAP note, that “appears to be falling asleep,” would be assigned to the Objective section. It can get confusing simply because of the nature of a therapy session. It’s great for medicine as “The patient has a 99.3 temperature” is clearly objective, but it can get murky when you’re dealing with mental health.
The Subjective and Objective sections of your note often begin to merge together in a behavioral health context. However, with a DAP note, that merging isn’t problematic, since it would all be recorded under the Data section.
It’s really just a mental exercise in terminology and how you record information, but in my opinion, DAP is a superior choice simply because it eliminates any ambiguity and gives you a clearer mental model with which to organize your thoughts.
DAP or SOAP — whatever you use is entirely up to you (or your administrators,) the important thing is to be consistent, record the data, and stay methodical and organized.
Writing Darp Notes
What clinical note formats do you use in your practice? Have any tips you’d like to share with the community? Leave a comment below and let us know!
Nursing Darp Notes
Writing mental health progress notes can be a challenging process. There are many aspects to consider when you create a record of psychological treatment. DAP notes provide mental health professionals with a guide for organizing pertinent information from psychotherapy sessions. Let’s take a closer look at the use of DAP notes.
What Are DAP Notes?
DAP is an acronym for Data, Assessment, and Plan. It is a simple and comprehensive template to help organize your notes. It is important to recognize that a DAP note is a progress note, not a personal psychotherapy note. That means it is part of the official record and can be shared with others. Let’s explore each part of the DAP note:
Data
The data component of DAP notes includes everything you heard and observed in the session. It is a review of all the information gathered. Most of this information is client self-report but clinician observations also provide valuable information. Although most of the data will be objective, the clinician, at times, may inject some subjectivity into the process. For example, they may note that a client “appears agitated”. An overall question that summarizes this section is “what did I see?”.
Assessment
The assessment portion of the DAP note reflects clinician interpretation. Here are some important questions to answer in the assessment section: Is the client making an effort to address their issues? How does the data reflect attention to their treatment goals? Are they making progress? Does the data indicate a particular diagnosis or issue to be addressed? In other words “what does the data mean?”
Plan
The final portion of the DAP note is the plan for future treatment. It may involve what you want the client to do next as well as what you, the therapist, want to accomplish. For instance, you may write that the client is to complete a homework assignment or that you need to contact their psychiatrist about their medication. Keep in mind, this segment is not the entire treatment plan. It is simply the goal from one session to the next. However, it may include changes or new directions to the overall treatment plan. It answers the question, what will I do next?
DAP vs. SOAP Notes
If you have ever taken progress notes as an employee of a large organization, you may have been asked to use the SOAP format. The SOAP (Subjective, Objective, Assessment and Plan) note is probably the most popular format of progress note and is used in almost all medical settings. The main difference between the SOAP and DAP notes is that the data section in a DAP note is split into subjective and objective parts. While this makes sense in a medical setting, it can be confusing when performing counseling. This is primarily because the objective part of therapy is hard to define. Almost everything that a clinician hears is subjective. As a result, you have no way of knowing if what your client is saying to you is true. In a medical setting, you have a lot of objective information, such as vital signs (e.g., temperature, blood pressure) and test results. The only objective information you have in a therapy session is the physical appearance of a client and maybe some psychological assessment results (and some may argue that they are objective too). That is why many mental health professionals prefer the DAP note. You don’t have to struggle to categorize information as objective or subjective; you can simply include it all as data.
Tips for Taking DAP Notes
Here are some considerations when taking DAP notes:
Make It a DARP Note?
Some people like to modify the DAP note into a DARP note, adding a place for a response after the assessment section. This is to record the client’s response to your assessments. Some clinicians believe the response provides essential information and should, therefore, have its own section. For example, say your client tells you they have consumed alcohol a few times this week after work. You might remark that they have been drinking a lot lately, especially after stressful days at work. Your client might get defensive upon hearing your assessment and start making excuses. Their defensive reaction is worth noting. In the DAP, the response is usually subsumed under the assessment piece but adding a separate section may remind you that it is important enough to consider separately. It is a matter of personal preference. Choose whatever is more effective for you.
Don’t Write Too Much or Too Little
Remember, DAP notes are for public consumption. No one wants to read a term-paper. At the same time, you need to include enough information so that someone else reading the note can understand what is happening. Bottom line: Include essential information and get to the point.
Know Your Audience
Ask yourself, who is likely to read this note? Because this is not a personal psychotherapy note, it needs to be professional in tone. While you may sometimes feel like writing progress notes is inconsequential, the information in the note may be used for important purposes. The DAP note, for example, could be used to decide a client’s medication regimen or as part of a malpractice civil suit. As any lawyer will tell you, once it is written down, it is part of the permanent record. Proceed accordingly.
Example of a DAP Note
The following is an example of a DAP note:
Name: Jane Doe Age: 25 Date: 2/1/20
Data: Client appeared a bit agitated. She was fidgeting and bouncing her leg. She reported that she had been cutting her thighs with a razor blade but denied suicidal intent or plan. She said the cutting makes her feel better. Client reported that she has been feeling a lot of financial and work stress. She would like to leave her job but feels she can’t due to the loss of income. Additionally, she is having trouble with a romantic relationship. She said that she is experiencing conflict with her mother and sister and can’t turn to them for advice.
Assessment: depressed mood and anxiety. She is under a lot of situational stress with limited emotional support. She also has some history of depression in her family. Denies suicidal ideation and has no history of suicidal behavior but is self-harming as a coping measure. When this therapist brought up the possibility of taking anti-depressant medication, she said she would consider it.
Plan: Give psychiatric referral for a medication evaluation. Continued assessment of self-harm and potential suicidality. Advise DBT skills to aid coping.
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