Documenting a behavioral health client’s progress can help streamline your practice and improve client outcomes. Different documentation methods can help behavioral health providers track client progress.
The most common documentation methods include Subjective, Operative, Assessment, and Plan (SOAP), and Data, Assessment, and Plan (DAP). Let’s take a closer look at both of these.
What is SOAP documentation format?
SOAP was originally created for medical records, but it is used in behavioral health care, as well. This format allows a clinician to record clear information consistently across client sessions. With this format, the clinician records information according to each letter of the acronym.
- Subjective: Less concrete information, such as a client’s history, concerns, and feelings
- Objective: Measurable details that can be tracked from one visit to another, such as psychological status
- Assessment: A diagnosis of the client based on the previous information
- Plan: Recommended treatment and other next steps for the client’s progress
Tips for taking SOAP notes
Although clinicians can take personal notes during client sessions, they should not write their official SOAP notes at the same time. Instead, providers can use their personal notes as a guide to create formal SOAP notes after the session is over. However, this should not be too long after the session, or else the clinician may forget helpful details.
Behavioral health professionals should be as specific as possible when writing notes in a SOAP format. The language should be non-judgmental without being too wordy. Anything included in SOAP notes should be clear and helpful to any other clinician who may need to read them.
What is DAP documentation format?
DAP is a slightly streamlined version of SOAP, used in much the same way. As with SOAP, a clinician following the DAP format will record data that corresponds to each letter of the acronym.
- Data: Here, the clinician records all documentable data related to a session. This can include both subjective and objective data, such as a client’s behavior or the feelings that he or she expresses.
- Assessment: The behavioral health clinician records a professional diagnosis or commentary on the client’s progress compared to previous sessions.
- Plan: The clinician writes down next steps for the client, including treatment steps, further assessments, or future appointments.
Tips for taking DAP notes
The Substance Abuse and Mental Health Services Administration offers a checklist and comprehensive guide for taking DAP notes, available as a downloadable PDF. This includes tips such as making sure the note is dated, signed, and legible, and that the client is accurately identified on each page.
The language of DAP notes should be clear and concise, with standardized and consistent abbreviations. Anyone unfamiliar with the client should still be able to read and understand the note. Documentation also should include non-routine calls or missed sessions, and any professional consultations the clinician may have engaged in related to this client or session.
Overall, there is little significant difference between SOAP and DAP notes. However, some behavioral health practitioners work with very little objective information. This means that the “O” in SOAP can be confusing or difficult to answer. In that case, DAP notes may be more useful.
Ultimately, the choice is yours, depending on your practice’s needs. Keep in mind that some payers, accrediting bodies, and regulators may have more specific requirements that affect your documentation.
Whichever notes format you prefer to use, your documentation tools should support your workflow. BestNotes EHR solution offers customizable documentation that never gets old. Contact us today to request a demo!