Clinical template
DAP Notes Template with Examples
A DAP note has three blocks: Data, Assessment, and Plan. Data is what SOAP splits into Subjective and Objective. Mental-health and counselling teams use DAP because a 50-minute session does not need a fake physical exam heading.
Blank DAP template
Copy this into Jane, an EMR, or a Scribeberry custom template. Keep Assessment as synthesis, not a second copy of Data. Number problems if the session covered more than one.
DAP note
Date / time / duration / modality: Clinician / designation / location: Client: [initials, age] | Session type: intake / follow-up / crisis / group D — Data What the client reported (symptoms, function, homework, life events): What you observed (affect, engagement, risk statements, relevant exam or vitals if taken): Measures today (PHQ-9, GAD-7, CIWA, etc.): Risk (SI/HI/self-harm) this encounter: A — Assessment Working diagnosis / formulation update / progress toward goals: What changed since last time: Risk formulation if it changed: P — Plan Interventions this session (if not already in Data): Homework / meds / referrals / safety plan: Next contact / who to involve:
Fictional patients
Every example on this page uses made-up names and findings. They are teaching material. They are not a substitute for college standards, billing rules, or your own clinical judgment. Review every generated note before it enters the chart.
DAP versus SOAP
Lawrence Weed's SOAP keeps the patient's story and your measurements in different drawers. That helps when the drawers are actually different: an abdomen exam is not a history of pain. In psychotherapy the 'exam' is mostly observation during the hour, so teams collapse S and O into Data. Assessment and Plan stay honest in both formats.
| SOAP | DAP | |
|---|---|---|
| Patient report | Subjective | Data |
| Exam, vitals, scales, what you saw | Objective | Data |
| Synthesis | Assessment | Assessment |
| What you will do | Plan | Plan |
| Best fit | Medical visits with a physical exam | Therapy, counselling, some nursing and social-work follow-ups |
Do not write a DAP that is a SOAP with the S and O labels peeled off and the same paragraph dumped twice. If you took blood pressure, it still belongs in Data. If you did not, do not invent an Objective section to look more medical.
Example 1 — therapy follow-up
CBT follow-up, session 8
29-year-old man, Vancouver. 50-minute video. Fictional.
D Session 8/12, video. GAD and panic, in CBT. Homework: three interoceptive trials (spinning in a chair). Completed two; skipped the third after a panic on the SkyTrain. GAD-7 = 9 (was 13). Sleep 7 h. No SI/HI. Affect initially tight, then engaged. Describes last week's panic as 8/10, 10 minutes, no ED visit. Continues escitalopram 10 mg via GP. A Panic disorder with agoraphobic avoidance, improving. Avoidance of the third interoceptive trial is the current maintaining factor, not a new diagnosis. Risk unchanged, low. On track for a 12-session package if he resumes the bodily-sensation work. P In session: mapped SkyTrain panic to the same feared sensation (dizziness) as the chair spin; designed a smaller trial (standing on one foot 60 s x 3). Homework: daily one-foot stands plus one short SkyTrain stop, not a full commute. Next session 7 days. GP remains MRP for meds; no change asked. Crisis plan unchanged.
Example 2 — family-practice counselling visit
GP, 20-minute mental-health visit
45-year-old woman, Fredericton. In-person. Fictional.
D Booked for "medication review" — actually grief after sister's death 8 weeks ago. Sleep 4–5 h, crying at work, still going in. PHQ-9 = 12, no anhedonia before the death. No SI. No alcohol increase. BP 128/80, weight stable. Sertraline 50 mg daily, started 3 weeks ago by me; mild nausea, taking it. Supportive sister-in-law in Moncton. A Bereavement with a moderate depressive overlay. Not a first presentation of melancholic depression. Sertraline too early to judge. Functioning at work is the watch item. P Continue sertraline 50 mg. Grief counselling referral (hospice community program). Offered short-term sick note; she declined. RTC 3 weeks or sooner if SI or she cannot work. Safety-net: ED / crisis line if she develops a plan. CPP updated: "grief, sister 2026" added to social, not to lifelong problem list.
Example 3 — addictions counsellor
Community OAT clinic, counselling
38-year-old man, Edmonton. 30 minutes. Fictional.
D Follow-up, opioid agonist treatment (buprenorphine-naloxone 16/4 mg SL daily, witnessed some days). Reports 12 days without fentanyl, two slips in the month before that. UDS last week: bup positive, fentanyl negative, methamphetamine negative. Housing: still in the shelter, wait-list for supported unit. Sleep poor on the shelter floor. No SI. Wants to talk about seeing his kids — supervised visits start Saturday. Observed: coherent, not intoxicated, mildly irritable when discussing the shelter. A OUD, currently abstinent from fentanyl on buprenorphine, housing instability threatening sleep and mood. Risk of return to use around the weekend visit if he has no plan for cravings. Not in withdrawal today. P Reviewed craving plan for Saturday (naloxone kit already dispensed; call clinic line; do not skip Sunday dose). Social worker to confirm visit logistics. I am not the prescriber; flagged irritability and sleep to the NP who writes the OAT. Next counselling Thursday. If he misses Sunday dose, he knows to present for assessment before a home dose.
Mistakes that collapse DAP back into mush
- Data that is only 'client attended and was appropriate.'
- Assessment that restates Data with the word 'therefore.'
- Plan with no date and no owner.
- Skipping risk because 'this is just a follow-up.'
- Pasting a full MSE into Data every week (see the therapy-notes page for when MSE belongs).
- Calling it DAP while still using S/O/A/P headings from a copied SOAP template.
Generate DAP in your session template
Scribeberry drafts Data, Assessment, and Plan from the visit or from dictation. Edit risk and the plan, then Smart Push into Jane, Accuro, OSCAR, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
What is a DAP note?
DAP stands for Data, Assessment, and Plan. Data holds what the client said and what you observed, including scales and risk. Assessment is your synthesis. Plan is the work after this encounter. It is the usual alternative to SOAP in mental health.
When should I use DAP instead of SOAP?
Use DAP when there is no useful split between history and physical exam — therapy follow-ups, counselling, many social-work visits. Use SOAP when vitals and a physical exam actually change the decision. Clinics should pick one format per service and stay with it.
Can DAP notes be used for billing in Canada?
The format is not a fee code. Provincial schedules pay for the insured service. The note has to show that the service happened: time, issues addressed, and a plan. Psychotherapy and mental-health codes still need the ingredients your schedule lists.
Does Scribeberry write DAP notes?
Yes. Choose a DAP template (or your own three headings), record or dictate, and generate. You review and edit before the note goes to the EMR. Custom templates keep Data/Assessment/Plan in your voice.
Templates
