With only three sections, DAP notes provide minimal structure to guide your documentation, so it’s important to understand what’s expected from each section of the note template.
Data
The data section is where you document any information collected from your session. This could include details the client has told you about their experiences and symptoms, anything you observed as a clinician that might reflect on their current situation, or any therapeutic interventions that you applied (including how the client reacted to them).
It’s a good idea to include person-centric details, such as direct quotes from the client, in the data section of your DAP progress notes. This serves two objectives: It helps insurance carriers verify that the session was authentic and unique, and it provides additional clinical insight into the client’s feelings and perceptions.
The data section is also where you’ll include any elements of the mental status exam, such as observations about the client’s appearance, mood, affect, thought process, and cognition.
Above all else, this account of the session should lay the groundwork for your assessment and plan.
Assessment
The assessment should include your client’s diagnosis, and your professional interpretation of the data collected from the session. You might note changes in your client’s mood or well-being since the last session, or an interpretation of their behavior that helped further your understanding of their condition.
This section can also include your assessment of the client’s current risk level.
The goal with this section is to provide a comprehensive understanding of the client’s mental health status, weaving together the data from the session with your clinically-informed analysis — which will inform your plan for treatment.
Plan
The plan section should include your roadmap for future sessions.
You may want to include any interventions you want to explore, goals for future treatment, or information about the timing and frequency of future sessions. You can also include the progress you’re making on your current treatment plan.
The plan section of a DAP note is similar to the plan sections of a SOAP note (subjective, objective, assessment, plan) or BIRP note (behavior, intervention, response, plan).