This is the third post in a series that highlights standardized formats for your clinical notes.  The series began here.

"Writing Scathing Notes" by JasonRogersFooDogGiraffeBee

A second format for documenting your clinical work is called DA(R)P notes, sometimes referred to as DAP notes.  These are similar to clinical SOAP notes. 

DA(R)P is a mnemonic that stands for Data, Assessment (and Response), and Plan.

Data, in this format, includes both subective and objective data about the client as well as the therapist’s observations and all content and process notes from the session.

The Assessment and Response includes your clinical impressions, hunches, hypotheses, and rationale for your professional judgment. Progress is also noted here.

Plan refers to your original treatment plan and any response / revisions needed based on your most recent interactions with your client.

This method of clinical note taking is also an acceptable format for your documentation.

Tomorrow I’ll talk to you about BASIC SID notes.

Tags: Assessment, DA(R)P Note, Treatment Plan

This is the second post in a series that highlights standardized formats for your clinical notes.  The series began here.

"Soap Carving" by Narisa Spaulding

Probably the most common form for standardizing your clinical notes is SOAP notes.  It’s likely that you learned how to document in this standardized form early on in your training as a mental health provider and you may have continued to use this format up until now.  SOAP is a mnemonic that stands for Subjective, Objective, Assessment, and Plan.

In this format, Subjective includes only the client’s subjective information.  Often this looks like a summary statement or direct quote from the client.

The Objective portion of your clinical note is observable data or information that coincides with the subjective statement.  Typically this includes the client’s body language and affect.

The Assessment is your professional and clinical judgment based on the aforementioned Subjective and Objective statements.

The Plan includes your intentions for future clinical work, any homework that was given, any referrals / interventions made, and any follow up needed or completed.

Many agencies and organizations use SOAP notes as their standard format for note taking.   Although it can be awkward and does not always easily permit the inclusion of data that you might feel is pertinent, SOAP continues to be a commonly accepted format for documentation of clinical notes.

Tomorrow I’ll talk to you about DA(R)P notes.

Tags: Assessment, Documentation, Follow Up, Homework, SOAP Note, Treatment Plan

On Monday, Brenda Bomgardner, a student intern at Regis University, wrote in asking for efficient ways to record her clinical notes.  This is the first of five posts to help you sort through your choices for clinical note taking.

"Leave Me Alone - I Know What I'm Doing" provided by foundphotoslj

You can be reasonably confident that  if you are working in an agency, the content and format for your clinical notes are already stipulated.  However, for those of you entering private practice, you have more leeway in deciding what your client notes, often called “progress notes“,  will look like.

All mental health disciplines require documentation of your clinical work.  Although the required content for that documentation varies from discipline to discipline and from jurisdiction to jurisdiction, there are general categories of information that are required for you to keep in your records. These categories typically include contact information, your client’s presenting problem, your assessment, treatment and plan.

In addition to free form notes, there are at least four common ways to standardize and record this information.  They are:

• SOAP Notes,
• DA(R)P Notes,
• BASIC SID Notes,
• and Gillman HIPAA Progress Notes.

Next week, I’ll share with you how each of these differs.  Then you can decide how best to keep your own clinical notes.

Do you know of other formats that you like to use?  If so, please share them with us here so that we may all learn from you!

Tags: Assessment, BASIC SID Note, DA(R)P Note, Documentation, Gillman HIPAA Progress Note, Presenting Problem, SOAP Note, Treatment Plan