DAP notes have become an increasingly popular annotation method for mental health care and behavioral health care practitioner. Therapists of every discipline use DAP notes to record and manage each patient’s case. They are especially helpful for keeping track of how a patient’s case evolves while ensuring that unexplored paths do not go unexplored in future sessions.
In this way, DAP notes effectively help to track the details of each therapy session while helping to inform the direction of the session after it. They are especially helpful for therapists and mental health care specialists who might see multiple clients on a given day. DAP notes allow a therapist to confidently “Change Gears” to meet each patient’s needs, trusting that they have captured all the pertinent details from the previous patient. This level of compartmentalization essentially allows for superior focus on each patient’s needs.
What Are DAP Notes?
The acronym “DAP” stands for Data, Assessment, and Plan. Some therapists will go as far as to add an R for Response, with patients who needed a response to a specific in-session topic. DARP notes might also be needed for patients who will need a response at the start of the next session. Though the “R” is more of an exception than the rule.
In their distilled form DAP notes are an efficient way for mental and behavioral health professionals to track the progress of their clients in an organized system. They also help to reduce the amount of time a therapist spends on documenting a session without sacrificing the quality of the information derived. At the same time, DAP notes also serve as part of the client’s official record and may be shared as well as viewed by others within the bounds of HIPPA compliance standards.
How Are DAP Notes Taken?
Each segment of DAP or DARP notes is recorded according to direct observations and interactions with the patient in the session in which the information is presented.
Data
These notes include direct observations during a session with the patient. These notes need to include all the relevant information the therapist gathered during the session. This includes the patient’s behavior, disposition, and responses to key questions and stimuli. This includes emotional responses to a specific topic as well as general information such as the patient’s overall mood during the therapy session.
Assessment
This is the phase of the notes where the therapist notes their assessment of the data collected during the session. The assessment notes are where the therapist applies their professional subjectivity for interpretation. It is also where the Data collected starts to transition from objective information to partially subjective interpretation.
Plan
This section of DAP notes is where the therapist makes informed decisions that help evolve the treatment plan as well as noting treatment goals that can be attained in future therapy sessions. In this way, the plan section is valuable for understanding what has been learned as well as indicating what progress has been achieved in the therapeutic process.
Response
This is an optional section used by some therapists and mental health care professionals as an extension of the “Assessment” phase of the notes. The response section basically records the client’s response to your professional assessment in a way that helps to enhance the effectiveness of future sessions.
What Is The Difference Between DAP Notes & SOAP Notes?
SOAP notes are “Subjective, Objective, Assessment, and Plan notations that have been used as a standard documentation and implementation tool throughout the healthcare industry. They tend to be used more for medical disciplines and specialists that are not engaged in the mental or behavioral health field. If a patient is receiving medical care in conjunction with mental healthcare, the primary physician might use SOAP notes. Whereas a therapist or behavioral specialist might use DAP or DARP notes.
How To Write Clear & Effective DAP Notes
There is a structure to DAP notes that needs to be followed in the proper sequence. This helps ensure that the information is flowing in an organized manner, while also saving the therapist time. The overarching goal is to decrease the time that providers spend on notetaking and documentation, without affecting the quality and efficacy of the information being recorded.
While everyone has their own style or protocol, most practitioners who have experience writing good DAP notes start by making a list of criteria that must be met in every section of the notes. This serves to standardize the information the therapist gathers and assesses in the process of evolving the treatment plan as well as meeting critical treatment goals.
Using Effective Documentation Tools
Different therapists have different ways of documenting their interactions with patients. Some use handwritten notes that are actively taken in the session. Others make verbal notes immediately following the session on some type of audio recording device. Whatever you prefer, the goal is to keep it consistent. This will reduce the risk of committing an error or forgetting to cover an important topic.
When writing the notes, try to keep them simple. Straight forward notes are easier to skim through later when you might need to brush up on a client before the next session. While you are writing your DAP or DARP notes make sure to only record the information that is relevant to the session and will help you build a better plan. This is especially important in the “Data” section of your DAP notes.
Reviewing DAP Notes
For patients who are seen frequently such as once or twice a week, it might be easy for you to keep their pertinent information in mind. In these cases, the DAP notes might be quick and easy to review.
For patients who are seen less frequently or those who often have lapses in scheduling a follow-up session, you might need to prioritize key items in the DAP notes. These less frequent patients are more likely to need an “R” response added to the notation process. The DARP notes then help you, the therapist, to key in on important issues from a previous session, and apply them to the treatment strategy.
