DAP Progress Notes
D – Data – a factual description of the session. It generally comprises 2/3 of the body of the note and includes the following information about the general content and process of the session.
· Subjective data about the client – what are his/her thoughts, activities, observations, desires, complaints, and self-reported problems, needs, limitations, strengths, and successes? AND
· Subjective data about the therapist’s activities and use of self – what is the therapist doing in response to treatment goals/objectives and client needs (e.g., therapeutic techniques being employed)?
· Objective data about the client – what was the therapist observing during the session about the client’s affect, mood, and appearance? “Client’s report of ____ and change in mood and affect suggest improvement of depression this week.”
· If therapeutic tasks, homework and/or behavior plans are a part of treatment, include comments about reviewing those items and tweaking assignments.
· Detail activities that reflect a clear association to the goals and objectives noted in the client’s treatment plan.
Document any referrals you make. This is generally included in plan on notes.
A – Assessment – an evaluation by the therapist of current status and progress toward meeting treatment goals. It generally includes information about:
· The therapist’s current working hypotheses about dynamics and diagnoses.
· The therapist’s description of client’s progress in response to the treatment.
· Perceived (YOUR perceptions about) client insights and motivation to change (readiness).
P – Plan – statements about what will happen next. It includes two (or three) things:
· When and what is the next session? (e.g., we will continue weekly individual therapy next week). If there will be a gap due to vacation, holiday, etc., note that. —
>>>Document any homework you are giving.
· What is the plan for the next session? (e.g., we will continue to focus on anger management, or we will include spouse and address communication issues).
· If new information becomes available, progress (or the lack thereof) occurs, additional problems arise, or the simple passage of time means a treatment plan update is needed, note that too, as a prompt to do the update next session.
· Any other info? Client s begin referred for any other service. ???with any other provider, or continuing to see someone else for services, e.g., case management? Medical provider? And so on…It could be that you are using this note and including in termination summary…..
Other Suggestions for DAP notes:
· Write legibly and use only black ink.
· Spell correctly and use full, grammatically correct sentences.
· For class, no abbreviations. LATER>>If permitted to use abbreviations, be careful (must be standardized and consistent).
· Content must be written in a way that even someone unfamiliar with the case can easily understand what occurred.
· Client name, number, date, time, and other top-of-the-page data elements must be completed.
· Sign every note.
· Do a note for each missed session (client cancellations / no shows).
