DAP is an acronym that stands for Data, Assessment, and Plan. These

types of notes are aimed at helping providers track the progress of

their clients in an organized and efficient way. As a professional,

utilizing DAP notes can help to cut down the time you spend on

documenting without sacrificing the quality of the information that you

input. It is important to note that as progress notes, they are

grammatically correct, clear, and use professional language. They are

part of the client record and can be requested, accessed, and read by

others including said client, insurance companies, judges, attorneys,

and other professionals.

The DAP note documentation method is very easy and can be broken

down into its three respective components: Data, Assessment, and

Plan.

The Data section of DAP notes includes everything that happened in the

session. This includes what the client said, what you observed during the

session, and basically anything you noticed about their behavior, disposition,

and response. Summarize the conversation, but when impactful statements

are made by the client, make sure to include them in quotes. You will also

include your interventions here and what evidence-based approach you

used. If you reviewed any homework from the previous session, this would

also be where you put it.

The Assessment section of DAP notes is where you analyze and assess the

facts written above. In this segment, you as the provider document your

interpretation of the content.

If your Data shows that a client respondednegatively, you might include what your understanding of the problem is andwhat working hypothesis you have regarding their response. The assessment part of the DAP note always begins with assessing for risk (SI, HI, and TOV), as well as the mental status examination (OA x4). Additionally, you will also assess progress towards their treatment goal in this section and if any formal testing or screening was done, it would also be included here.

The plan section of DAP notes is essentially the time in which the provider

explains what happens next. Here, the recommendations of continued

treatment are put including type and frequency (ex. Weekly individual

sessions, bi-weekly family sessions, a med-management appointment within

the next week, etc.) Furthermore, homework given to the client is recorded

in this section and the next scheduled session is put on here.

Although it might sound cumbersome, a DAP note should really be no

more than 1 or 2 paragraphs per section. The Data section is typically

the longest part of the note and it can be tempting to put everything

the client stated or shared in that section. However, succinct and

salient is the goal, so summarizing will be your best bet!

Data: John presented for the session neatly dressed and groomed. He

reported he has continued to take his prescribed anxiety medication and

feels “well”. He reported he is doing and feeling “fine” overall, but shared

that the problems with his wife continue to get worse. John spent the

session discussing his plans to attempt to work less so he can help out at

home with the kids more, as he suspects this is the main source of his wife’s

resentment towards him and the root of their issues. This therapist engaged

in empathetic listening and encouraged John to seek work-life balance.

Additionally, this therapist engaged in psychoeducation on how stress affects

the brain and the responses he could be having with his wife as a result of

no downtime. John was receptive to the information and agreed many times

he just “snaps” at his wife and kids after work for no reason. Therapist

utilized CBT techniques to help John identify when he is getting to a low

frustration tolerance and how to stop before he snaps.

Assessment: John engaged actively in today’s session. He had no

SI/HI/TOV and was OA x4. He was able to discuss his feelings and take

accountability for his actions. John is showing more insight into his anger

and continues to progress toward the goal to control his outbursts.

Plan: John is to continue with weekly individual therapy sessions and

attempt to ask his wife if she would be willing to do a couple’s session within

the next two weeks. He will practice thought-stopping techniques learned in

today's session and report back on how this went. Next session is scheduled

for 06/26/2022 at 5pm.

Data: Gina presented for the session in pajamas and was disheveled. She

said she forgot about the appointment and was “annoyed” that she had to

get up to join. Therapist engaged in curiosity and empathy, then asked if the

client wanted to discuss how her week had been. Gina responded that she

“didn’t really feel like talking” as she felt like “it doesn’t help anyway.”

Therapist utilized MI and gathered that the client is no longer medication

compliant, and is feeling extremely hopeless. Additionally, she is drinking

heavily every night to go to sleep. She was disengaged from the

conversation and was unwilling to share any other information.

Assessment: Gina was severely disengaged in today's session. Due to her

increased sense of hopelessness, this therapist performed a C-SSRS and

determined she was at a level 4 risk (Non-specific active suicidal thoughts.)

This therapist created a safety plan with the client and she is to follow it if

her ideations increase. Gina is showing regression in her treatment and her

increased alcohol consumption could result in the need for a higher level of

care.

Plan: Gina is to continue with weekly individual therapy sessions and get

back on her medications ASAP. She is to meet with her NP within the next

week to discuss how to best do so. Gina will follow the safety plan provided if her ideation increases at any time. Next session is scheduled for 06/30/2022 at 7pm.

D.A.P. Progress Note Checklist