Today, electronic health records (EHRs) help physicians provide better quality care and better manage patients. 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.
Keeping proper mental health progress records is essential to provide patients with the care they need. The two common methods of mental health documentation are:
- SOAP (Subjective, Operative, Assessment and Plan), and
- DAP (Data, Assessment, and Plan)
According to the American Psychological Association (APA), it is up to the psychologist to balance various considerations and adopt the appropriate approach to keeping records. Let’s take a look at the SOAP and DAP note formats and how they benefit psychologists, therapists, and other practitioners.
Developed in the 1950s, the main purpose of SOAP notes is to help providers monitor patients with multiple conditions. 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.
Subjective: This section describes subjective elements such as the patient’s feelings/views or the comments of family or a person close to them. Documentation includes the chief complaint, present symptoms, medical and family health history and changes in functioning.
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. While symptoms are documented in the Subjective section, signs should be noted in the Objective section. Current medication details and allergies may be included in either the Subjective or Objective sections.
Assessment: This section documents the physician’s impressions and interpretations based on the information documented in the Subjective and Objective sections. The aim of the assessment is to arrive at a correct diagnosis, though this may not happen at the initial visit. All possible diagnoses – differential diagnoses – should be documented from the most to least probable, along with diagnositic decision-making.
Plan: The information in the above three sections are combined to develop the treatment plan and further treatment steps. The Plan should include action to be taken for each diagnosis to help future providers understand what steps to take next. There should be separate plans for multiple conditions.
The DAP note aims to helping mental health professionals document and track the patient’s progress in an organized and efficient manner. This simple, comprehensive template is part of the official record and can be shared with others. If it includes Response, this note format would be written as DARP.
Data: In the data component, the provider has to document everything heard and observed in the session. This mostly comprises self-reported information but also includes important observations of the therapist. While the data will be mostly objective, the clinician may include some subjectivity. For example, if they may note that the client “appears agitated”. The question “What did I see?” is the gist of this section.
Assessment: The DAP note assessment section documents the clinician’s interpretation. Important questions to answer include: Is the client making an effort to resolve their issues? Are they making progress? What does the data mean – does it point to a particular diagnosis or issue to be addressed?
Plan: This portion comprises the plan for future treatment, including changes or new directions to the overall treatment plan. It could include both what the therapist wants the client to do next and what they want to accomplish as a therapist. This segment is not the entire treatment plan, but simply the goal to accomplish from one session to the next. It answers the question, what will I do next?
How do DAP Notes differ from SOAP Notes?
The basic difference between DAP and SOAP notes is that the DAP note merges the Subjective and Objective elements under the Data section. The SOAP note splits data into the Subjective and Objective parts. The SOAP note is useful in a medical setting where there is a lot of objective data such as vital signs (e.g., temperature, blood pressure) and test results.
While counseling and therapy may be considered a form of “health care”, these behavioral health interventions do not have the same diagnostic data as medicine does. In behavioral therapy, taking notes is crucial to collect comprehensive information. Therapists use observation and interviewing to arrive at a diagnosis and develop a treatment plan. In a therapy session, the only objective information would be the physical appearance of a client and some psychological assessment results. All the other information collected during the encounter would be subjective. Many of the things documented by the therapist are not quantifiable.
Unlike the medical setting, in the mental healthcare scenario, it is not easy to determine what is objective versus subjective. With the DAP note, data does not have to be categorized as subjective and objective. It can be merged and simply included in the data section. That’s why many mental health professionals prefer DAP notes.
How to write Good DAP Notes
Structured note taking is important to save time and include all the information needed to make assessments and treatment plans. Here are some tips to write quality DAP notes:
- Use the best documentation tools built with DAP note structures
- Keep the notes simple: include only relevant information collected in the session
- Make sure the information can help build a strategy for the patient
- Ensure accuracy and make sure the notes are easy to follow
- When including the patient’s words, use quotation marks
- Review the dates and times of occurrences, and spellings
- Use standard procedures to make corrections
EHRs allow healthcare providers to work collaboratively and provide each patient with a comprehensive, responsive care plan. Regardless of which note-taking format they prefer to use, the support of an experienced medical transcription service organization can be crucial for ensuring accurate and timely EHR documentation.