This simple, comprehensive template is part of the official record and can be shared with others. The DAP note aims to helping mental health professionals document and track the patient’s progress in an organized and efficient manner. There should be separate plans for multiple conditions. The Plan should include action to be taken for each diagnosis to help future providers understand what steps to take next. Plan: The information in the above three sections are combined to develop the treatment plan and further treatment steps. All possible diagnoses – differential diagnoses – should be documented from the most to least probable, along with diagnositic decision-making.

The aim of the assessment is to arrive at a correct diagnosis, though this may not happen at the initial visit. Current medication details and allergies may be included in either the Subjective or Objective sections.Īssessment: This section documents the physician’s impressions and interpretations based on the information documented in the Subjective and Objective sections. While symptoms are documented in the Subjective section, signs should be noted in the Objective section. Objective: In the mental health scenario, the objective part of SOAP notes relates to the functioning of the body and neurological function assessment with the Mental Status Exam.Evaluation and review of the documentation of other clinicians is also included in this section. Documentation includes the chief complaint, present symptoms, medical and family health history and changes in functioning. Subjective: This section describes subjective elements such as the patient’s feelings/views or the comments of family or a person close to them. Patients who are seen by several specialists needed to have comprehensive medical record with notes from every consultation so that they could be correctly evaluated by any physician. SOAPĭeveloped in the 1950s, the main purpose of SOAP notes is to help providers monitor patients with multiple conditions. Let’s take a look at the SOAP and DAP note formats and how they benefit psychologists, therapists, and other practitioners. SOAP (Subjective, Operative, Assessment and Plan), andĪccording to the American Psychological Association (APA), it is up to the psychologist to balance various considerations and adopt the appropriate approach to keeping records.The two common methods of mental health documentation are: Keeping proper mental health progress records is essential to provide patients with the care they need. In the field of behavioral health, EHRs supported by mental health transcription services offer many benefits such as better collaboration among providers, improved medication management and crisis management, health information privacy and security, and much more. Today, electronic health records (EHRs) help physicians provide better quality care and better manage patients.

Darp notes examples