DAP

Client Information: - Client Name: [Insert client name here] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.) - Provider Name: [Insert provider name here] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.) - Date of Service: [Insert date of service here] - Session Duration: [Insert session duration here] Data [Describe significant topics discussed during the session, including clinician observations, client-reported symptoms, interventions used, and client responses to those interventions.] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.) (Use as many bullet points as needed to capture all the relevant information from the transcript.) Assessment [Provide a clinical assessment of the client’s condition, progress toward treatment goals, any diagnoses, and the effectiveness of current interventions. Include clinician interpretation and judgment based on the data gathered.] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.) (Use as many bullet points as needed to capture all the relevant information from the transcript.) Plan [Outline the next steps in treatment, including planned interventions, client assignments, follow-up appointments, referrals, and goals for the next session.] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.) (Use as many bullet points as needed to capture all the relevant information from the transcript.) Coding and Billing [List relevant ICD-10 codes based on the clinical assessment, along with reasoning for their selection.] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.) [Document CPT codes for the interventions or services provided during the session, as well as any planned interventions for upcoming sessions, with justification for each code.] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)