Whether you're a newly licensed therapist still finding your documentation style, a practice manager aiming for team consistency, or a med student unsure of where to start — you need to know how to handle clinical notes.

In many ways, they're the backbone of quality care and legal compliance.

It might sound like a lot of pressure. But it doesn't have to be stressful.

DAP (Data, Assessment, and Plan) notes offer an effortless, intuitive format for clear clinical documentation.

In this guide, you'll learn what DAP notes are, how they compare to other popular note-taking formats, and the best practices to write them effectively.

We've gathered insights from experienced mental health professionals, therapists, and healthcare experts, highlighting common mistakes and how to avoid them easily. 

By the end, you'll feel confident writing DAP notes—saving valuable time and boosting patient care.

TL;DR:

• DAP notes are a structured format for clinical documentation that mental health professionals use.
• They consist of Data, Assessment, and Plan sections for clear and concise notes.
• Writing DAP notes effectively involves capturing session details, evaluating progress, and outlining next steps.
• Avoid common mistakes like vague descriptions, delayed documentation, and missing risk documentation.
• Adapting DAP notes to EHR systems can improve workflow and care coordination.

What is a DAP note? 

A DAP note is a structured clinical documentation format commonly used by mental health professionals — like psychologists, counselors, psychiatrists, and allied health clinicians in OT or PT.

The format breaks down notes into three sections:

• Data
• Assessment
• Plan

Unlike it's popular counterpart, the SOAP note, DAP notes are focused on flow and simplicity. In many ways, they streamline record-keeping, make it easy to reference critical information quickly and promote effective communication among care teams. 

How to write DAP notes

Understanding how to write a DAP note effectively keeps our medical documentation clear, helpful, and compliant . In this section, you’ll learn just that. 

We took the insights from A Therapist’s Guide to Writing in Psychotherapy, written by therapist and author Michael D. Reiter, and from other experienced mental health and healthcare professionals. 

Let’s start with the Data section of the DAP note. 

Data 

The Data section captures what happened in the session—what was said, observed, and experienced. You write the information gathered during the session as a story, including patient quotes and observations. 

Unlike some other progress note formats (more on this later), like SOAP, vitals like heart rate and blood pressure aren’t mandatory in DAP notes. However, you should add them if they are clinically relevant to your session, assessment, or treatment plan. For example, if there’s a change in physical health that may influence mental status (e.g., elevated blood pressure during a panic attack).

Write chronologically so that others can easily replay the session. Reiter says,

“You want to paint a picture of the progression of the session, focusing on both the general themes and topics while still highlighting the most important details and reflections from the client.”

Here are some more things he suggests: 

• Clearly attribute statements to patients: "Client stated..." or "Client reported…"
• Include relevant details like mood, affect, grooming, and engagement, as they show the patient's overall assessment. 
• Use direct quotes sparingly to avoid clutter.

Focus on meaningful details that impact the session’s assessment and planning. 

In some therapy settings, you may be encouraged to avoid language that presents observations as absolute facts. This is a simple way to protect yourself legally while still documenting clearly. Use observation verbs such as "appeared," "seemed," or "was observed to..." to maintain objectivity and avoid liability issues.

The Data section is a reference point you can return to for tracking progress or spotting concerns like substance use or suicidal thoughts. Highlight key insights, note any risks, and include safety plans if needed. The goal is to document clearly and meaningfully so that your observations connect directly to the client’s clinical picture.

Assessment

You bring clinical insight into the session’s data in the Assessment section. It’s your space to evaluate progress, identify patterns or risks, and make clinical judgments—not simply restate what happened.

A common error many make in this section is being vague. 

As Dr. Chad Walding, Doctor of Physical Therapy and Co-Founder at NativePath, explains,

“A quality DAP note should include a specific assessment component that ties in the treatment. 

Instead of writing ‘Patient shows minimal progress with increased mobility,’ we should write ‘Patient reports 30% decreased pain with increased hip mobility during gait.’’ He adds that the latter is significantly more detailed and presents a more succinct picture of the patient's clinical presentation."

This level of specificity doesn’t just paint a clearer picture — it supports better care planning and improves communication between care providers. 

A thoughtful assessment connects the dots between what you observed and how the client responds to treatment, setting the stage for what comes next.

Plan

The Plan section logically outlines the next steps based on your assessment. It includes actionable, personalized recommendations such as treatment goals, interventions, referrals, and follow-up schedules. Defined expected outcomes help guide future sessions.

In his book, Reiter notes that the following details are usually included in the Plan section:

• Homework assignments
• Upcoming intervention strategies
• Topics for future sessions
• Updates to the overall treatment plan
• Referrals or adjustments in session frequency and treatment intensity

💡 Pro Tip: Build the plan to work on two levels — a session-to-session roadmap and an overarching treatment timeline.

For example, you can plan to hold weekly check-ins to practice calm-breathing drills, targeting a 50% drop in average worry scores by the end of the eight-week program.

Ensuring your plan is clear, actionable, and directly linked to your assessment will enhance patient care continuity and therapeutic effectiveness.

Mistakes to avoid while writing DAP notes

Even the best clinicians need reminders. Here are some simple ways to keep your DAP notes clear, accurate, and effective. 

• Missed session details: Not listening closely or missing key info in the Data section can create gaps. Include important subjective and objective observations, even if they seem minor.
• Vague or wordy descriptions: Be specific. Instead of “Client was upset,” try, “Client appeared tearful when discussing their father.” Precision helps everyone on the care team understand what’s going on.
• Skipping clinical context: Don’t overlook observable shifts like changes in mood, grooming, or affect. These details matter, especially when assessing risk or progress over time.
• Copy-pasting old notes: Each session is different. Tailor your notes to reflect what happened rather than recycling past entries.
• Delayed documentation: Write your notes while the session is still fresh. Waiting too long can lead to missed or forgotten insights.

Quality control is important

“Once I learned that it is better to review notes at the end of the day rather than rely on memory, I have not left anything out that would alter treatment moving forward. Quality control is a personal preference.”— Dr. Chad Walding. 

• Making assumptions: If something isn’t clear, ask. Clarifying what a client means shows respect and strengthens the therapeutic relationship, making your notes more accurate.
• Disjointed flow between sections: Ensure all the sections connect logically. Each one should naturally build on the previous one.
• Missing risk documentation: Always document risk-related conversations. If the patient mentions self-harm, suicide, violence, or other safety concerns, include your assessment and any safety planning steps.
• Forgetting compliance basics: Be aware of privacy laws and your EHR’s documentation standards. Accuracy, timeliness, and confidentiality always matter.

Adapting DAP notes to EHR systems

Most Electronic Health Record (EHR) systems come with pre-built templates and formatting quirks that can make note-taking feel clunky. The good news? DAP notes are flexible enough to fit your workflow without sacrificing clarity or clinical value.

Here are a few ways to make DAP notes work beautifully within your EHR:

• Maintain core structure: Create a DAP note template with the Data, Assessment, and Plan divisions to ensure clinicians can easily locate essential information.  Standardize the adapted templates across your practice to maintain consistency. 
• Make it easy to scan: Use clearly labeled fields like “Client’s response” or “Session goals,” so clinicians can quickly find what they need.
• Save time with smart tools: Drop-down menus and checklists can speed things up. Use them for everyday observations, goals, or interventions; just be sure there’s space to personalize where needed.
• Link progress notes to treatment plans: Ensure your DAP notes are directly linked to the patient’s overall treatment plan within the EHR to support continuity of care and help track progress over time.
• Securely attach supporting documents: If you have additional documents, such as referral letters, attach them securely to the DAP note within the EHR to keep all relevant patient information in one place.
• Regularly review EHR settings: Periodically review and update your DAP note templates to reflect any changes in practice guidelines, legal requirements, or personal preferences.
• Train your team: If you’re working with a group, ensure everyone knows how to use the DAP format in your EHR. A shared structure means smoother care.

Thoughtful EHR setup doesn’t just improve documentation—it makes care coordination smoother and note-taking less stressful.

DAP note examples and template

Knowing how to write a DAP note is one thing — seeing it in action is another. Below are two fictional DAP note examples that show how each section works together to form a clear, clinically sound record.

Example 1: Initial assessment for depression

Data: The client presented for an initial assessment session, appearing fatigued with minimal eye contact. The client reported experiencing persistent sadness, stating, "I just don't feel like myself lately," and described difficulties sleeping, loss of appetite, and reduced enjoyment in previously pleasurable activities over the past three months. Observed affect was flat, mood appeared dysphoric, and grooming was neat but minimal. Client denied suicidal ideation or substance use when directly questioned.

Assessment: The client exhibits symptoms consistent with a depressive episode, including low mood, disrupted sleep patterns, decreased appetite, and anhedonia. Symptoms have impacted daily functioning and interpersonal relationships—no immediate risk of self-harm or substance misuse observed or reported, but mood instability warrants close monitoring. Baseline severity appears moderate.

Plan: Initiate weekly individual therapy sessions focused on cognitive behavioral techniques targeting mood elevation and behavioral activation. Assign client journaling homework to monitor mood variations and activities. Next week's Follow-up session will evaluate journal entries and discuss coping strategies for improving sleep hygiene. Reassess symptom severity bi-weekly with a goal of a 50% reduction in depressive symptoms over eight weeks.

Example 2: Follow-up session for anxiety

Data: Client attended the third follow-up session for generalized anxiety disorder, appearing visibly tense and speaking rapidly at session onset. Client reported, "This week was tough; my anxiety spiked several times," citing increased worry about work performance. I observed the client practicing calming breaths during the session, visibly reducing physical tension and improving engagement by mid-session. Affect appeared anxious initially, becoming calmer post-intervention practice.

Assessment: The client demonstrates continued anxiety symptoms, notably exacerbated by work-related stressors. However, the client effectively applied calming techniques introduced in prior sessions, showing a tangible reduction in physical and emotional anxiety symptoms. The client’s proactive use of techniques during the session indicates developing coping skills and potential for further improvement with practice.

Plan: Continue weekly therapy, reinforcing calming breath and mindfulness techniques. Assign client homework to practice calming breath exercises at least twice daily, documenting anxiety triggers and the effectiveness of interventions. The next session will focus on cognitive restructuring strategies to address workplace anxiety. Aim to decrease overall anxiety symptom severity by 40% within the next four weeks, adjusting frequency or intensity of sessions as progress warrants.

No approach to writing DAP notes is absolute

There’s no one-size-fits-all method for writing DAP notes. The DAP structure stays the same—Data, Assessment, Plan—but how you document within it can vary.

As Racheal Turner, a trauma and relationship therapist based in Arizona, says,

“I tailor my DAP notes to reflect deeper emotional and relational patterns rather than just surface-level symptoms.”

She integrates language from trauma-informed modalities like IFS, EFT, and EMDR to note shifts in self-compassion, internal parts, or physiological responses, making her documentation both clinically relevant and aligned with her therapeutic approach.

Your DAP notes should serve your clients and your practice. That might mean adapting the language to reflect trauma work, behavioral therapy, or medical rehabilitation, as long as the documentation is clear, accurate, clinically sound, and actionable.

Comparing SOAP, DAP, and BIRP notes

While DAP is widely used and appreciated for its clarity, it’s just one of several effective documentation formats. The best note-taking style often depends on your clinical focus and personal workflow. 

Let’s see the difference between a DAP, SOAP, and BIRP note.

DAP notes differ from SOAP notes in that they combine the Subjective and Objective sections into one called Data. This section includes information gathered during a session through client questions and personal observations.

Subjective, Objective, Assessment, and Plan format, or SOAP notes, are a go-to in medical and interdisciplinary environments. Their structured format makes it easy to track vital signs, symptoms, and measurable outcomes across teams.

In contrast, DAP notes strike a thoughtful balance, combining the simplicity of fewer sections with a narrative style favored by therapists. Moreover, fewer sections mean less clicking and scrolling within EHRs—a significant practical benefit in busy outpatient practices.

BIRP (Behavior, Intervention, Response, Plan) notes specifically support behavior-focused interventions, emphasizing detailed tracking of client behaviors and responses, making them perfect for behavioral therapy contexts.

Here's a quick comparison to help you pick the right format for your needs:

Wrapping up: smarter notes, better care

Effective clinical documentation delivers consistent, compliant, and compassionate care. DAP notes make this easier by organizing clinical insights into Data, Assessment, and Plan, cutting down on clutter while keeping your notes clear and actionable. However, the best format depends on your practice’s needs and preferences.

That’s where AI-powered digital scribes, tools that generate clinical notes by converting audio to a structured format, like Freed, come in. 

Freed streamlines note-taking so you can focus more on your client and less on your keyboard. It listens to your patient conversation and converts it into accurate notes using artificial intelligence.  

While it currently generates notes in the SOAP format, therapists can easily adapt them to DAP: just combine the Subjective and Objective sections into your Data, while Assessment and Plan transfer directly.

If you’re in a practice that prefers DAP, it takes just one step to adapt Freed’s output. And if your team uses a different format? You can still try it out—no EHR setup or IT support required.

Try Freed's AI scribe to stay efficient, compliant, and focused on what matters most — delivering excellent care.

Try Freed and see how much lighter your charting can feel.