To write progress notes in dap, follow the organizational format of data, assessment and response, and plan. Clinical notes of progress that are written in dap format include contact information, a summary and evaluation of the problem, and plans for treatment. Take your notes by hand in a notebook or on a computer using a word processing program.
- Write the data section of the notes
The data section is the main component of your notes. Include contact information for the patient, subjective and objective data, and your observational notes from the session. Subjective data is a summary of information given to you by the client and may include direct quotes. Objective data includes the information you notice as you interact with the patient, including body movements and facial expressions.
- Write the assessment and response section of your notes
The assessment and response is a summary of your professional ideas and opinions based on the subjective and objective information that you have collected. Include your feelings, thoughts and ideas, as well as rationale for your ideas. Observations regarding your perceived progress of the patient are recorded here as well.
- Write the plan section of your notes
Record the treatment plan you decide upon for your client in this section. Make note of any changes that you make to the plan based on the ongoing relationship you form with the client. Include thoughts for work to be done in upcoming sessions and notes on any referrals or interventions that have been completed or that are recommended.