DAP Notes for Therapists, Format, Examples, and Template

A concise three-part documentation format common in private practice and outpatient psychotherapy. Data, Assessment, Plan, collapses SOAP's subjective and objective sections into one combined Data section.

DAP structure breakdown

  • DData

    Both patient-reported (subjective) and observed (objective) information combined, what the patient said, mental status findings, scale scores, behavioural observations. SOAP's S and O sections merged.

  • AAssessment

    Clinical interpretation, ICD-10 diagnosis, severity, scale interpretation in context, change from prior visit, treatment response. Identical scope to SOAP Assessment.

  • PPlan

    Next steps, interventions, medication changes, follow-up frequency, referrals, scales to readminister, homework. Identical scope to SOAP Plan.

Example: established-client anxiety follow-up

  • Fictional example

    Date: 2026-04-24 Time: 11:00–11:45 (45 min, 90834) Diagnosis: F41.1 Generalized Anxiety Disorder Client: M.K., established, age 41 D: Data Client reports anxiety "still pretty constant but the sleep meditation is helping a little." Sleeps 5–6 hours nightly, up from 4. Reports continued worry about work performance, financial stability, family. Denies panic attacks since last visit. No SI. Med adherence good. GAD-7 administered: 13 (down from 15 last visit). PHQ-9: 6. MSE: cooperative, mildly anxious affect, normal speech, no psychomotor agitation. Insight intact. A: Assessment F41.1 in active treatment showing modest but real improvement (GAD-7 -2 points, sleep gains). Comorbid mild depressive symptoms (PHQ-9 6) without functional impact. Worry content remains generalized across multiple domains, consistent with GAD vs more circumscribed anxiety presentation. No emergent panic disorder. Risk: low. P: Plan Continue sertraline 100 mg. Continue weekly CBT focused on cognitive restructuring + worry exposure. Add 5 minutes of daily progressive muscle relaxation between sessions. Re-administer GAD-7 at next visit (2026-05-01). If improvement plateaus by 2026-06, consider augmentation discussion. CPT: 90834 + 96127×2 (GAD-7 + PHQ-9)

    Same clinical content as the SOAP example would contain, Data combines what the patient reported with what was observed, then Assessment and Plan proceed identically.

Example: PTSD in trauma-focused CBT

  • Fictional example

    Date: 2026-05-12 Time: 15:00–15:55 (55 min, 90837) Diagnosis: F43.10 Post-Traumatic Stress Disorder, Unspecified Client: A.T., established, age 29, session 9 D: Data Client reports nightmares down to twice in the past week (most nights at intake) and drove past the crash site once without pulling over. Still avoids highway driving. Sleep 6–7 hours. Denies SI. PCL-5 administered: 41 (54 at intake, 47 four weeks ago). PHQ-9: 9. MSE: cooperative, mildly guarded when describing the crash, normal speech, no dissociation observed. Insight good. A: Assessment F43.10 responding to treatment: PCL-5 down 13 points from intake, past the 10-point drop that indicates response, though still above the 31–33 provisional cut-off range. Avoidance of highway driving is the main remaining target. Mild depressive symptoms (PHQ-9 9). Risk: low. P: Plan Continue weekly trauma-focused CBT. Begin graded exposure to highway driving: one short stretch with a support person before next session. Re-administer PCL-5 at session 12. Review sleep if nightmares stop decreasing. CPT: 90837 + 96127×2 (PCL-5 + PHQ-9)

Copy-ready template

  • Date
    —
    Time
    —
    Minutes
    —
    Diagnosis
    —
    Client
    —
    Session
    —
    CPT
    —

    D Data

    Client self-report (mood, sleep, appetite, stressors, side effects). Mental status exam findings. Scale scores: PHQ-9 ___, GAD-7 ___, PCL-5 ___, AUDIT ___ (whichever administered). Behavioral observations.

    A Assessment

    Clinical interpretation of Data. Diagnosis confirmation or update. Severity, change from prior, treatment response. Risk assessment if relevant.

    P Plan

    Interventions, medication changes, frequency, referrals, scales to re-administer, between-session tasks, safety planning.

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DAP vs SOAP, when to choose which

  • Use DAP when

    • Private practice, outpatient psychotherapy
    • Solo practitioner, no multi-disciplinary handoffs
    • Patient self-report and observation overlap heavily
    • Conciseness matters (high session volume)
    • Payer accepts DAP format on contracts

  • Use SOAP when

    • Multi-disciplinary settings (medical + behavioural)
    • Payer or accreditor requires SOAP structure
    • The S/O distinction is clinically important (somatic-symptom presentations)
    • Training environments where the discipline of separating self-report from observation supports skill development
    • Default-friendly: works for any payer

Documenting MBC scale scores in DAP

  • For sessions billing CPT 96127, each scale unit billed must include in the note:

    1. Scale name and score in the Data section ("GAD-7 administered: 13").
    2. Severity band and change from prior in Assessment ("GAD-7 13, moderate severity, down 2 points from last visit").
    3. Treatment-plan implication in Assessment + Plan ("Modest improvement consistent with current treatment plan; continue current approach; readminister at next visit").

    The clinician's reasoning is what 96127 reimburses, not the patient self-completing the form. Notes that record only the score without interpretation are at risk of denial.

Common ICD-10 / CPT pairings for DAP notes

    • F41.1 + 90834 + 96127×1 (GAD-7), anxiety follow-up
    • F33.1 + 90834 + 96127×1 (PHQ-9), depression follow-up
    • F60.3 + 90834 + 96127×2 (PHQ-9 + GAD-7), DBT-informed individual therapy
    • F31.81 + 90834 + 96127×2 (MDQ + PHQ-9), bipolar II maintenance

Measurement-based care

…starts with what we measure, and how long.

Frequently asked questions

  • What does DAP stand for in therapy notes?

    Data, Assessment, Plan. Three-part format that consolidates SOAP's subjective and objective sections into a single Data section, then proceeds with Assessment and Plan.

  • What goes in the Data section?

    SOAP's Subjective and Objective sections merged into one. Include patient self-report, mental status findings, and validated scale scores together rather than in separate sections.

  • When should I use DAP instead of SOAP?

    DAP works well in private practice and outpatient psychotherapy where the S/O split feels redundant. SOAP is the default for multi-disciplinary settings, payer-friendly contracts, and presentations where the report-vs-observation gap matters clinically.

Sources & Citations

    1. 1.Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling & Development, 80(3), 286–292.
    2. 2.U.S. Department of Health & Human Services. HIPAA Privacy Rule and Sharing Information Related to Mental Health.
    3. 3.American Medical Association. Current Procedural Terminology (CPT) 2026, code 96127 documentation requirements.