What goes in the Data section of a DAP note?

Both subjective and objective information combined: patient self-report (mood, sleep, appetite, stressors, side effects, direct quotations), observable mental status findings, validated scale scores (PHQ-9, GAD-7, etc.), and behavioral observations. Unlike SOAP which separates these into S and O sections, DAP collapses them into one.

What goes in the Plan section of a DAP note?

Next steps: treatment recommendations, medication adjustments, therapeutic interventions, frequency of follow-up, referrals, scales to readminister, between-session homework, and any urgent action steps. Same content as SOAP's Plan section.

What is an example of a DAP note for therapy?

D: Patient reports increased anxiety this week related to work deadlines; GAD-7 score 14 (moderate), affect anxious, psychomotor restlessness noted, denies SI. A: F41.1 Generalized Anxiety Disorder, current episode partially controlled, worry content situational rather than free-floating. P: Reviewed cognitive restructuring on catastrophizing; assigned thought record homework; continue weekly sessions; readminister GAD-7 in 2 weeks; consider escitalopram referral if no improvement in 3 weeks.

How long should a DAP note be?

Most DAP notes for a 45-minute outpatient psychotherapy session are 150 to 300 words, organized with brief paragraphs or bulleted entries under each section. The length should be proportional to the clinical complexity, not the session duration. A medication-stable maintenance visit may produce a tighter note; a crisis visit, safety planning encounter, or treatment-plan revision will run longer because more clinical reasoning needs to be documented.

Are DAP notes accepted by insurance?

Yes. U.S. payers do not mandate a specific note format, only that the documentation supports the billed CPT code with elements like date, diagnosis, intervention, response, and plan. DAP satisfies these requirements. SOAP is the more familiar default across multi-disciplinary settings, but DAP is fully acceptable for outpatient psychotherapy claims (90832, 90834, 90837) and for measurement-based care add-ons like CPT 96127.

DAP Notes for Therapists, Format, Examples, and Template

Q: What does DAP stand for in therapy notes?

DAP stands for Data, Assessment, and Plan. It is a three-part documentation format that consolidates patient-reported (subjective) and observable (objective) information into a single Data section, then proceeds with the clinician's Assessment and the Plan. DAP is concise and common in private practice and outpatient psychotherapy.

Q: What goes in the Assessment section of a DAP note?

The clinician's interpretation of the Data: ICD-11 diagnosis (or differential), severity assessment, scale interpretation in context, change from prior visit, treatment response, comorbidity considerations, and risk assessment if relevant. Same content as SOAP's Assessment section.

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-patient anxiety follow-up

Date: 2026-04-24 Time: 11:00–11:45 (45 min, 90834) Diagnosis: F41.1 Generalized Anxiety Disorder Patient: M.K., established, age 41 D: Data Patient 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.

Copy-ready template

Date: ____ Time: ____ – ____ (___ min, CPT ____) Diagnosis: ____ (ICD-11) Patient: ____, ____ session D: Data [Patient 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.] CPT: ____ + 96127×__ (scales administered)

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:

Scale name and score in the Data section ("GAD-7 administered: 13").
Severity band and change from prior in Assessment ("GAD-7 13, moderate severity, down 2 points from last visit").
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

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

← All note formatsSOAP notes →BIRP notes →