DAP Progress Note Template
Client/ID: John Doe
Therapy Provider: Dr. Kieran McLeod
Session Date: October 5, 2023
Start and Finish Time: 10:00 AM - 11:00 AM
Data:
John Doe presented with increased anxiety and depressive symptoms, reporting difficulty sleeping and a lack of appetite. He appeared disheveled and had poor hygiene. During the session, cognitive-behavioural therapy (CBT) techniques were employed to address negative thought patterns. John responded well to guided relaxation exercises but remained visibly distressed when discussing recent stressors, including job loss and relationship issues. The PHQ-9 screener indicated a moderate level of depression.
Assessment:
John's current diagnosis of Major Depressive Disorder remains unchanged. He denied any suicidal or homicidal thoughts. Progress towards treatment goals has been slow, with significant areas needing attention, particularly in managing anxiety and improving sleep hygiene. Johnβs engagement in therapy is positive, but his overall mental health status requires close monitoring.
Plan:
The treatment plan includes continuing CBT with a focus on anxiety management and sleep improvement. John was given homework to practice relaxation techniques daily and to keep a sleep diary. A referral to a sleep specialist was made to address ongoing insomnia. Key takeaways for John include recognising and challenging negative thoughts. The next session is scheduled for October 12, 2023, at 10:00 AM in the same location.
DAP Progress Note Template
Client/ID: [mention client's name or ID if applicable](only include if mentioned)
Therapy Provider: [mention name of clinician or counselor](only include if mentioned)
Session Date: [mention session date](only include if mentioned)
Start and Finish Time: [mention session start and finish time if applicable](only include if mentioned)
Data:
(In this Data section, record all observed data during the session including the client's presenting problems or reasons for the session, their mental status, appearance/hygiene, interventions used, responses to interventions, and any assessment or screener results, etc. This section combines subjective and objective information about the session to provide detailed documentation of the collected information. It includes anything discussed during the session, observations made about the client, and relevant details about the clientβs subjective experience. Write a paragraph in narrative style using full sentences. Never use bullet points. Use as many sentences as needed to capture all the relevant details under this section.)
Assessment:
(In this Assessment section, provide a detailed assessment of the client's progress including current diagnosis, any changes to their diagnosis, evaluations of self-harm, suicidal thoughts, or homicidal thoughts, how the client is progressing towards treatment goals, areas that need attention, etc. Write a paragraph in narrative style using full sentences. Never use bullet points. Use as many sentences as needed to capture all the relevant details under this section.)
Plan:
(In this Plan section, describe the treatment plan in detail including any updates or revisions based on current session, describe the goals, objectives and interventions discussed, describe the strategy for future session such as detailing actionable steps including any homework or tasks for the client, referrals to other organizations or professionals, key takeaways for the client to reflect on, and the date, time, and location of the next session. Write a paragraph in narrative style using full sentences. Never use bullet points. Use as many sentences as needed to capture all the relevant details under this section.)
(Never come up with your own patient details, assessment, diagnosis, interventions, evaluation, and plan - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant section blank.)(Use as many sentences as needed to capture all the relevant information from the transcript into one of the three sections above, whichever one is most appropriate. Never use bullet points. Be specific and provide detailed information for each section of the note. Clearly distinguish between objective and subjective information, especially in the Data section. The clinician should be able to easily identify the two and not confuse subjective with objective information. Specify who said what and who perceived what to separate the client's input from clinician's observations.)
