Creating effective notes for your therapy sessions doesn’t have to be a daunting task. Many clinicians have found that using DAP notes is the best way to take notes in a quick, useful, and effective manner. Of course, before using DAP notes you’ll need to understand the basics behind them and get a few tips for how you can use the technique for your notes.

Feb 17, 2016 Subjective: Symptoms or covert data based on patient's perceptions, sensations, feelings, values, beliefs and attitudes. Objective: Signs that are detectible through senses by an observing, interviewing and examining. What nurses did based on the assessment/evaluation of the. Registered users can save articles, searches, and manage email alerts. All registration fields are required.

DAP Notes Basics

Below is a fictional example of a progress note in the SOAP (Subjective, Objective, Assessment, Plan) format. For the purposes of this sample progress note, the focus is on the content of the progress note, rather than the format. The sample offers examples of what the SAPC QI and UM. A DAP note is to be filled out each time you meet with a client for a CLEAR session. Please use the questions and statements listed below each section as a guide to what information needs to be included in order to ensure that this note is a complete explanation of the information shared during the session. Specific, FACTUAL information. This is a quick video from the University of Calgary that covers the basics in how to write clinical patient notes. It covers some key principles that prote.

The first step in writing DAP notes is understanding the format. Let’s evaluate each section.

D – Data

When writing in this section you’ll want to take note of what you observed during the session. This could be any relevant behavior, especially those that might affect the way you proceed with treatment.

A – Assessment

After you’ve recorded the relevant behaviors, you’ll use this section to understand what those behaviors mean. Essentially, you’ve collected your data and now you need to analyze it. What do you think that action or actions mean?

P – Plan

This is the final piece of your note-taking puzzle. You’ve gathered data through observation, you’ve assessed the data accordingly, and now you’ll use what you’ve learned to record the treatment plan for your patient.

That’s the basics of DAP notes. It's simple enough, right? Of course, you want to use the technique in a way that’s beneficial to you.

3 Tips for Making DAP Notes Work

1. Define Your Perfect Note

When writing your notes, it helps to understand what perfection looks like to you. Yes, your notes will not be perfect, because no note truly is, but you need to understand the outcome you’re looking for before you can know if you got close to it. We’ve already defined each section and what guidelines say they should have, once you decide to use this method you have to tailor that information to fit your needs. Ask yourself – What information do I need about my patient and this session to be able to create a plan for them? If someone else were writing these notes, what information would I find usable and helpful?

After you’ve answered these questions for yourself you can begin to determine how each section of your therapy notes should look. For instance, maybe your data section contains phrases that are only 3 to 5 words in length to give you quick details of what you see while your assessment section features longer sentences that provide the detail you need regarding what you wrote in the data section. What matters is that each section allows you to use the information contained there in a quick and effective manner.

2. Keep It Simple

You want to get as much valuable information from your notes as possible, but you don’t want to overcomplicate them. Start getting familiar with the information you don’t want to include in your notes and the information you need to include. You don’t need to record that you adjusted the temperature as your patient entered the room, but you may want to note your patient’s demeanor as they greeted you. What you want to avoid is a bunch of words on the page that look thorough but ultimately can’t be used. This may take some practice, but it’s a habit you’ll be happy you developed.

3. Use the Tools that Work Best for You

Another piece of the process you need to consider is what you’ll be using to take your notes. Is it more effective for you to use an online template to take notes or would you prefer writing your notes on paper then transferring them online? When you’re deciding which is best for you, you’ll want to keep the result you’re working towards in mind. Are your handwritten notes sloppy and hard to understand? Do you find that you can’t type as fast as you think? You might have to work with both for a while before you get a handle on the best method to use going forward.

If you aren’t sure which method works best for you, you can always start with templates that you can either print or use online. Using a template will give you the opportunity to make sure you are recording the information you need each time. If you use the same template on and off-line, you’ll have the opportunity to gauge which technique works best for you (and saves you the most time). You can also take things a step further and use a HIPAA compliant EHR that allows you to record and save notes for future review.

If you’re interested in the ways that My Client’s Plus can help you with note-taking or other aspects of your practice, don’t hesitate to sign up for a free trial or contact us for more information.

OT practitioners spend lots of time on documentation.

Our notes help us track patients’ progress, communicate with other healthcare providers, and defend our rationale for our treatment choices. Documentation is a key factor in our patients’ well-being during their continuum of care.

But, as we all know, charting can take FOREVER—and we might not have the time we need to do it justice.

We are constantly grappling between wanting to write the perfect OT note—one that succinctly says what we did and why we did it—and finishing as quickly as possible.

My vision (and I’ll admit it’s a grand one) is to help you create the type of notes that clearly communicate your assessments and plans, without making you lose your mind in the process.

We’ll start with some basic do’s and don’ts of effective documentation. Then, at the end of the article, you’ll find a sample OT evaluation and some more resources to help you improve your note-writing game.

A quick shout-out: Thank you to The Note Ninjas, Brittany Ferri (an OT clinical reviewer), and Hoangyen Tran (a CHT) for helping me create this resource!

Do’s and Don’ts of writing occupational therapy documentation:
(We’ll take one SOAP note section at a time)

Subjective (S)

DO use the subjective part of the note to open your story

Each note should tell a story about your patient, and your subjective portion should set the stage.

Try to open your note with feedback from the patient about what is and isn’t working about their therapy sessions and home exercise program. For example, you can say any of the following to get your note started:

“Patient states she was excited about ____.”
“Patient reports he is frustrated he still can’t do ____.”
“Patient had a setback this past weekend because ____.”

Driver broadcom for mac. By sentence one, you’ve already begun to justify why you’re there!

DON’T go overboard with unnecessary details

Let’s admit it: we are storytellers, and we like to add details. But, we must admit we’ve all seen notes with way too much unnecessary information. Here are a few things you can generally leave out of your notes:

“Patient was seated in chair on arrival.”

Do’s and Don’ts of writing occupational therapy documentation: (We’ll take one SOAP note section at a time)

Subjective (S)

DO use the subjective part of the note to open your story

DON’T go overboard with unnecessary details

Do’s and Don’ts of writing occupational therapy documentation:
(We’ll take one SOAP note section at a time)

Darp Notes Examples