Creating effective notes for your therapy sessions doesn’t have to be a daunting task. Many clinicians have found that using DAP notes is the best way to take notes in a quick, useful, and effective manner. Of course, before using DAP notes you’ll need to understand the basics behind them and get a few tips for how you can use the technique for your notes.
DAP Notes Basics
The first step in writing DAP notes is understanding the format. Let’s evaluate each section.
D – Data
When writing in this section you’ll want to take note of what you observed during the session. This could be any relevant behavior, especially those that might affect the way you proceed with treatment.
A – Assessment
After you’ve recorded the relevant behaviors, you’ll use this section to understand what those behaviors mean. Essentially, you’ve collected your data and now you need to analyze it. What do you think that action or actions mean?
P – Plan
This is the final piece of your note-taking puzzle. You’ve gathered data through observation, you’ve assessed the data accordingly, and now you’ll use what you’ve learned to record the treatment plan for your patient.
That’s the basics of DAP notes. It's simple enough, right? Of course, you want to use the technique in a way that’s beneficial to you.
3 Tips for Making DAP Notes Work
1. Define Your Perfect Note
When writing your notes, it helps to understand what perfection looks like to you. Yes, your notes will not be perfect, because no note truly is, but you need to understand the outcome you’re looking for before you can know if you got close to it. We’ve already defined each section and what guidelines say they should have, once you decide to use this method you have to tailor that information to fit your needs. Ask yourself – What information do I need about my patient and this session to be able to create a plan for them? If someone else were writing these notes, what information would I find usable and helpful?
After you’ve answered these questions for yourself you can begin to determine how each section of your therapy notes should look. For instance, maybe your data section contains phrases that are only 3 to 5 words in length to give you quick details of what you see while your assessment section features longer sentences that provide the detail you need regarding what you wrote in the data section. What matters is that each section allows you to use the information contained there in a quick and effective manner.
2. Keep It Simple
You want to get as much valuable information from your notes as possible, but you don’t want to overcomplicate them. Start getting familiar with the information you don’t want to include in your notes and the information you need to include. You don’t need to record that you adjusted the temperature as your patient entered the room, but you may want to note your patient’s demeanor as they greeted you. What you want to avoid is a bunch of words on the page that look thorough but ultimately can’t be used. This may take some practice, but it’s a habit you’ll be happy you developed.
3. Use the Tools that Work Best for You
Another piece of the process you need to consider is what you’ll be using to take your notes. Is it more effective for you to use an online template to take notes or would you prefer writing your notes on paper then transferring them online? When you’re deciding which is best for you, you’ll want to keep the result you’re working towards in mind. Are your handwritten notes sloppy and hard to understand? Do you find that you can’t type as fast as you think? You might have to work with both for a while before you get a handle on the best method to use going forward.
If you aren’t sure which method works best for you, you can always start with templates that you can either print or use online. Using a template will give you the opportunity to make sure you are recording the information you need each time. If you use the same template on and off-line, you’ll have the opportunity to gauge which technique works best for you (and saves you the most time). You can also take things a step further and use a HIPAA compliant EHR that allows you to record and save notes for future review.
If you’re interested in the ways that My Client’s Plus can help you with note-taking or other aspects of your practice, don’t hesitate to sign up for a free trial or contact us for more information.