DAP Notes Template
This AI-powered DAP notes template helps psychiatrists, psychologists, and mental health nurses document therapy sessions. With Heidi, the AI medical scribe for all clinicians, you can instantly generate DAP notes that:
- Capture key therapy details through a clear Data, Assessment, and Plan structure.
- Provide insights into the patient’s condition and progress.
- Keep records organized and focused to support future sessions.
What is a DAP Notes Template?
A DAP notes template is a structured format used by healthcare professionals to capture essential information during therapy sessions. The acronym stands for Data, Assessment, and Plan.
In this article, we’ll share a step-by-step guide on how to write DAP notes, provide various examples of DAP note usage across different specialties, explain how DAP notes differ from BIRP and SOAP notes, and give you free customizable DAP notes templates you can edit based on your practice’s needs.
How to Write a DAP Note: Step-by-Step Guide
Below is a detailed breakdown to help you write effective DAP notes.
Step 1: Document Relevant Data
The first section, Data, should capture objective and subjective information shared and observed during the session, including:
- Patient-reported symptoms(mood swings, stressors, physical symptoms).
- Behavioral observations (body language, engagement/detachment, emotional expression).
- Interventions used (cognitive behavioral therapy, mindfulness exercises).
Example: Austin reported persistent feelings of sadness, difficulty sleeping, and low energy. He expressed frustration about workplace conflicts and appeared tense when discussing interactions with his manager
Step 2: Provide an Assessment
The Assessment section is your professional evaluation of the session.This includes:
- Progress or setbacks compared to previous sessions.
- Patient’s engagement level and ability to apply coping strategies.
- Clinical impressions regarding mental or behavioral health status.
Example: Jamie exhibited increased willingness to discuss workplace stressors but still struggles with assertive communication. His difficulty setting boundaries suggests an ongoing challenge with self-advocacy. Mood has shown mild improvement since the last session, but anxiety remains a concern. No signs of self-harm or suicidal ideation.
Step 3: Outline the Plan
The Plan section details next steps for treatment, including:
- Recommended interventions (therapy techniques, referrals, medication adjustments).
- Homework assignments (journaling, mindfulness exercises).
- Follow-up schedule (next session, check-in calls).
Example: Continue working on assertive communication skills with guided role-play in the next session. Assign daily journaling on work stress triggers and practice one assertive response per day in real-life situations. Follow-up session scheduled in one week to evaluate progress.
DAP Note Examples: Applications Across Specialties
DAP notes are a structured yet flexible approach to documentation; this makes the format compatible with various healthcare specialties. Below are sample DAP notes to give you a better idea as to how they’re utilized in different fields of healthcare.
1. Mental Health & Counseling DAP Notes
Psychologists, therapists, and social workers often use the DAP note format to document therapy sessions.
Example:
Client/ID: Sean M.
Therapy Provider: Dr. Abigail Marston
Session Date: May 27, 2025
Start and Finish Time: 1:00 PM - 3:00 PM
Data:
Sean reported feeling overwhelmed at work, struggling with motivation, and experiencing increased anxiety. He described frequent headaches and trouble sleeping. During the session, cognitive-behavioral therapy (CBT) techniques were used to address negative thought patterns. He was receptive to guided relaxation exercises but expressed difficulty implementing self-care routines.
Assessment:
Sean continues to experience work-related stress and generalized anxiety. He is engaged in therapy but struggles with consistency in applying coping strategies. No signs of self-harm or suicidal ideation were present.
Plan:
Continue with CBT, focusing on stress management and self-care integration. Sean was assigned daily mindfulness exercises and asked to log his stress triggers. The next session is scheduled for June 3, 2025.
2. Substance Use Treatment DAP Notes
Addiction counselors and rehabilitation specialists use DAP notes to detail patient progress in substance user recovery programs.
Example:
Client/ID: Mark S.
Therapy Provider: Jordan Reeves, LADC
Session Date: March 3, 2025
Start and Finish Time: 10:30 AM - 11:30 AM
Data:
Mark reported strong cravings over the past week due to increased work stress but stated he did not relapse. He attended four out of five scheduled group therapy sessions and found them helpful. He discussed feeling frustrated with family members who do not understand his recovery journey.
Assessment:
Mark is maintaining sobriety but experiencing emotional distress related to stress and family dynamics. His coping mechanisms are improving, though cravings remain a challenge. He expressed commitment to recovery but requires additional support in managing external pressures.
Plan:
Increase participation in peer support groups. Introduce stress-reduction techniques, including mindfulness and journaling. Explore potential family counseling in future sessions. Follow-up scheduled for March 10, 2025.
3. Behavioral Health & Case Management DAP Notes
Case managers and behavioral health specialists use DAP notes to track patient needs, interventions, and progress in mental health programs.
Example:
Client/ID: Maria L.
Case Manager: David Nguyen, LMSW
Session Date: February 28, 2025
Start and Finish Time: 1:00 PM - 2:00 PM
Data:
Maria expressed frustration with her housing situation and financial stress. She recently missed two medication doses due to difficulty picking up prescriptions. She reported feeling emotionally exhausted and overwhelmed but denied self-harm or suicidal thoughts. Discussed available community resources for financial and housing assistance.
Assessment:
Maria is experiencing high stress due to financial instability, which is impacting her mental health. Medication adherence issues need to be addressed to avoid setbacks in her treatment.
Plan:
Coordinate with a social worker to explore emergency rental assistance programs. Assist Maria in setting up medication delivery to improve adherence. Schedule a check-in call before the next session on March 6, 2025.
DAP Note vs SOAP Note vs BIRP Note
DAP notes, SOAP notes, and BIRP notes each serve a similar but distinct purpose in healthcare documentation.
DAP notes (Data, Assessment, Plan) focus on key observations, professional assessment, and next steps.They offer a structured yet flexible format, making them ideal for counseling, case management, and behavioral health cases.
SOAP notes (Subjective, Objective, Assessment, Plan) follow a highly structured format that emphasizes medical objectivity. They’re widely used in hospitals, physical therapy, and psychiatric care. The “Objective” section is unique to the SOAP note template, since it includes quantifiable data such as vital signs, lab results, and diagnostic test results.
BIRP notes (Behavior, Intervention, Response, Plan) are designed specifically for behavioral health documentation. Compared to DAP and SOAP notes, they place greater emphasis ondocumenting patient behaviors and responses to interventions.
DAP Notes Template Example
On top of their already demanding daily schedules, clinicians often have to work after hours to complete their DAP notes for each client. Fortunately, with the help of AI-powered health care solutions, we can offer you a more efficient way to streamline your DAP note documentation– so you can focus more on patient care and less on paperwork.
Easily Complete DAP Notes with Heidi
Meet Heidi, our high-tech AI medical scribe designed to help you write DAP notes while you’re conducting your therapy sessions. With your patient’s permission, simply hit record and let Heidi work alongside you!
Before Heidi, Dr. Richard Bloom often had to stay extra hours at his clinic or take his work home just to complete his surgical notes. Now, he’s able to draft notes in real-time, and he never has to worry about missing important information again.
“It's way more accurate than what my handwritten notes were. I'm sometimes even surprised by some of the things that it includes… I read the output and I think, actually, we did talk about that!”
Here’s how Heidi helps you accomplish your DAP notes:
- Transcribe - Open Heidi on your computer or mobile device and press Start. Conduct your session as normal while Heidi captures everything in the background.
- Customize - After the session, pick your preferred DAP note template and watch as Heidi perfectly transcribes the details of your conversation into the appropriate Date, Assessment, and Plan format!
- Transform - After generating your DAP note template, you can ask Heidi to give additional documentation including referral forms if needed.
Heidi adhere to jurisdiction-specific regulations, ensuring data localization for customers in Australia, Canada, the United States, and the United Kingdom. Read more about our compliance here.
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Free DAP Note Templates [Customizable]
DAP Report Template
Mental health professionals and clinical physiologists can use this comprehensive template to document psychological and medical issues, along with client goals and structured DAP and SOAP notes.
DAP Note Template
Therapists can use this template to document therapy sessions using the DAP note framework (Data, Assessment, Plan).
FAQs About DAP Note Templates
How do DAP notes improve patient care?
DAP notes help healthcare providers maintain clear, organized and consistent documentation for each therapy session. This helps them track patient progress, identify necessary treatment adjustments, and ensure seamless communication (especially for referrals) so patients can receive continuous care.
How do you write a good DAP note?
To write good DAP notes, you must keep them concise but informative, while avoiding assumptions and excessive detail. Using neutral, professional language is always ideal. It’s also important to ensure that DAP note documentation is consistent across sessions for continuity of care.
Are DAP notes still HIPAA-compliant when generated via AI-enabled templates?
Yes, AI-generated DAP notes can be HIPAA-compliant if the software used adheres to strict data security and privacy regulations. Heidi is compliant with HIPAA, ISO 27001, and SOC 2 standards to ensure patient data is securely recorded, stored, and managed.