How to write client treatment plans quickly and efficiently, according to therapists
These tips can help you stay focused.
Here’s how to decide which progress note-taking style is right for you.
Writing progress notes is an important part of your job as a therapist. Thankfully, you don’t have to stare at a blank page after each session. There are a variety of progress note-taking styles, all with templates that simplify the writing process.
If you’re considering which types of progress notes you’re interested in using, read on. We’ve compared two popular styles of notes — SOAP and DAP notes — to help you decide which is right for you.
SOAP notes are a specific format for writing progress notes as a behavioral health clinician. They contain four primary sections, represented by its acronym:
If you’re using a SOAP note template and filling out every section as directed, you should feel good about how your notes stack up to compliance expectations. Each section of a SOAP note is designed to help you document the most critical aspects of your session for compliance with insurance billing, including elements of a mental status exam and risk assessments.
A SOAP note is typically concise, usually ranging from two to four paragraphs in length. The specific length can vary depending on complexity of the patient's condition, but therapists aim to be thorough yet succinct.
A SOAP note’s holistic approach naturally encourages you as a provider to collect comprehensive insight about your client and their treatment. And because SOAP notes are widely recognized and used in many different healthcare settings, other care providers can easily recognize and review your mental healthcare records to provide continuity of care for your clients.
Headway’s built-in note-taking feature uses a SOAP note template, and includes one-click check boxes to help you fulfill the mental status exam and risk assessment on your notes.
DAP notes are a specific format for writing progress notes as a behavioral health clinician. They contain three primary sections, represented by its acronym:
DAP notes provide a very simple through line that helps you reflect on your progress with a client: Data is about what happened in the session, assessment is your clinical interpretation of the data, and the plan is where you chart a path forward for future sessions based on your assessment of this one. Each component directs your focus to capturing the most critical parts of your session.
Typically, DAP notes are three paragraphs long, with one paragraph for each component of the format (data, assessment, and plan). The specific length can vary depending on complexity of the patient's condition, but therapists aim to be thorough yet succinct.
SOAP notes and DAP notes are very similar. The primary difference is how the observations from the session are structured:
Both include assessment and plan sections that prompt a clinician to reflect on their interpretation of the session and document how they’re proceeding with care.
Therapists tend to use the format they were trained on, and whichever one feels most authentic to their style and modality. Any of these can be insurance compliant and which one you use is generally a matter of personal preference.
You might choose a SOAP note if you prefer more structure to your note taking, or if it’s important to dedicate space to monitoring specific symptoms from a clinically objective point of view.
SOAP notes can be great for medical or multidisciplinary settings where detailed, structured documentation is crucial for communicating treatment plans and client progress across providers. Learn how to write a SOAP note.
You might choose a DAP note if you prefer to take a more straightforward and efficient approach to documentation, focusing on the client’s data, your assessment, and the planned treatment without unnecessary complexity. With fewer sections, DAP notes may also be faster to complete than SOAP notes, for example, for some providers.
“I might not recommend DAP notes for a newer therapist, because in that case structure is a good thing,” says Natalia Tague, a licensed counselor in Virginia. “If you're more experienced and you’d prefer a shorter format, then maybe DAP is for you.” Learn how to write a DAP note.
While there are many options for documentation, Headway's in-product templates are designed to make note-taking fast and efficient, all while helping to take out the guesswork.
Plus, our templates are included at no additional cost for Headway providers.
Headway’s team and tools are here to make everything about working with insurance companies (including compliance!) as easy as possible.
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