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This DAP notes template helps psychiatrists, psychologists, and mental health nurses document therapy sessions. With Heidi, you can instantly generate DAP notes that:
A DAP notes template is a structured format used by healthcare professionals to take note of essential information during therapy sessions. The acronym stands for Data, Assessment, and Plan.
Below, you'll find a step-by-step guide to writing DAP notes, worked examples across different specialties, a comparison of DAP, BIRP and SOAP formats, and free customisable templates you can adapt to your practice.
To write effective DAP notes, here's what to include in each section:
The first section, Data, should note objective and subjective information shared and observed during the session, including:
Example: Austin reported persistent feelings of sadness, difficulty sleeping, and low energy. He expressed frustration about workplace conflicts and appeared tense when discussing interactions with his manager
The Assessment section is your professional evaluation of the session.This includes:
Example: Jamie exhibited increased willingness to discuss workplace stressors but still struggles with assertive communication. His difficulty setting boundaries suggests an ongoing challenge with self-advocacy. Mood has shown mild improvement since the last session, but anxiety remains a concern. No signs of self-harm or suicidal ideation.
The Plan section details next steps for treatment, including:
Example: Continue working on assertive communication skills with guided role-play in the next session. Assign daily journaling on work stress triggers and practice one assertive response per day in real-life situations. Follow-up session scheduled in one week to evaluate progress.
DAP notes take a structured yet flexible approach to documentation, which suits a wide range of clinical specialties. Below are sample DAP notes showing how the format is used across different clinical fields:
Psychologists, therapists, and social workers often use the DAP note format to document therapy sessions.
Example:
Client/ID: Sean M.
Therapy Provider: Dr. Abigail Marston, Registered Psychologist
Session Date: 2025-05-27
Start and End Time: 13:00 – 15:00
Data:
Pt presents c/o severe occupational stress, ↓ motivation, and ↑ generalised anxiety. Reports concurrent frequent tension headaches and secondary sleep disturbance/insomnia. CBT techniques used to address maladaptive cognitions. Pt receptive to guided relaxation exercises in-session but notes ongoing barriers to independent self-care integration.Assessment:
Clinical impression consistent c/w ongoing work-related distress and features of GAD. Pt well-engaged in tx but experiences difficulty c/ independent compliance regarding coping strategies between sessions. Denies SI/HI; no active intent or plan present. Safety risk remains low.Plan:
Cont CBT framework, focusing on stress mgmt and self-care pacing. Pt to attempt daily mindfulness exercises and maintain log of acute stress triggers. RTC on 2025-06-03.
Addiction counsellors and rehabilitation specialists use DAP notes to track patient progress through substance use recovery programs.Example:
Client/ID: Mark S.
Therapy Provider: Jordan Reeves, Registered Psychotherapist (RP)
Session Date: 2025-03-03
Start and Finish Time: 10:30 – 11:30
Data:
Pt reports severe cravings over past week secondary to ↑ occupational stress; denies any substance use or lapses. Attended 4/5 scheduled group tx sessions, noting them as beneficial. Expressed significant frustration regarding fam dynamics and a perceived lack of familial support/understanding regarding his recovery journey.
Assessment:
Clinical impression c/w ongoing Substance Use Disorder (SUD) recovery. Pt maintaining abstinence but experiencing concurrent emotional distress related to stress and fam conflicts. Coping mechanisms showing improvement, though cravings remain a distinct challenge. Pt remains highly motivated for recovery but needs stronger strategies for managing external pressures. Denies SI/HI; safety risk is low.
Plan:
Encourage ↑ attendance at peer support networks. Introduce further stress-mgmt techniques, including mindfulness and journaling. Explore feasibility of future family counselling sessions. RTC on 2025-03-10.
Case managers and behavioural health specialists use DAP notes to track patient needs, interventions, and progress in mental health programs.
Example:
Client/ID: Maria L.
Case Manager: David Nguyen, MSW, RSW
Session Date: 2025-02-28
Start and Finish Time: 13:00 – 14:00
Data:
Pt reports significant distress re: housing instability and ongoing financial stressors. Confirms missing x2 medication doses recently, secondary to transit/pickup barriers at the pharmacy. Reports feeling emotionally exhausted and overwhelmed by current socioeconomic factors. Denies SI/HI or intent for self-harm. Navigated and discussed available municipal/provincial community resources for urgent financial and housing navigation support.
Assessment:
Clinical impression reveals high situational distress secondary to socioeconomic and housing instability, which is negatively impacting pt's psychiatric baseline. Medication non-adherence identified as a critical risk factor requiring prompt intervention to prevent clinical regression or acute symptom exacerbation. Pt safety risk remains low at present.
Plan:
Liaise c/ municipal emergency rental assistance and local rent bank programs to address housing crisis. Assist pt c/ setting up direct pharmacy delivery to address transit barriers and improve medication adherence. Schedule brief telephone check-in mid-week. RTC on 2025-03-06.
DAP notes, SOAP notes, and BIRP notes each serve a similar but distinct purpose in healthcare documentation.
DAP notes (Data, Assessment, Plan) focus on key observations, professional assessment, and next steps. The format is structured yet flexible, making it well suited to counselling, case management, and behavioural health.
SOAP notes (Subjective, Objective, Assessment, Plan) follow a more rigid structure built around medical objectivity. They are widely used in hospitals, physical therapy, and psychiatric care. The "Objective" section sets them apart: it captures quantifiable data such as vitals, lab results, and diagnostic findings.
BIRP notes (Behaviour, Intervention, Response, Plan) are built for behavioural health documentation. Compared to DAP and SOAP notes, they emphasise patient behaviours and responses to interventions.
You can download a copy of this document, or auto-fill it seamlessly with Heidi, your AI care partner.
After a full day of sessions, DAP notes can easily eat into the evening. An AI healthcare solution like Heidi changes that. Generate your notes during the session itself and leave the clinic with the paperwork already done.
The DAP note is where the session ends and the paperwork begins. With Heidi as your AI Care Partner, it is also where the rest of your documentation takes care of itself.
At the Ottawa Institute of Cognitive Behavioural Therapy (OICBT), this is already reality. Clinicians there cut documentation time by 66% (from 213 to just 71 minutes a week) and reported lower cognitive load, sharper focus, and more presence with patients. As Dr. Pete Kelly, Clinical Psychologist and CFO at OICBT, put it:
"Heidi is helping our clinicians restore balance and presence in their work. By introducing efficiencies that reduce after-hours documentation, our team can focus on patient care instead of paperwork. We're seeing more engagement, less burnout, and a foundation for a more sustainable practice."
Here’s how Heidi helps you accomplish your DAP notes:
Trusted by clinicians across Canada and built to meet PIPEDA and applicable provincial health privacy law, Heidi handles the paperwork so the session stays yours.
Clear, consistent DAP notes make it easier to track progress, catch when a treatment plan needs adjusting and keep communication tight across referrals. For patients, that means fewer gaps in care.