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.

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.

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!