The optimal way to create mental health progress notes is a subject of debate among therapists. Some people prefer to keep their records as complete as possible, while others only include the information that is absolutely necessary. Each strategy has its own set of advantages and disadvantages. So, how can you figure out which option is ideal for your practice?
Keeping strong mental health progress records is important for guiding clients to the greatest possible outcomes, as well as for your personal reference and protection, and for other practitioners who might need to see the notes. However, with so many options — digital vs. hard copy, and detailed vs. concise – it can be tough to determine what to include and what to leave out.
SOAP and DAP notes are the most prevalent of the several forms of mental health notes. But, before we get any farther with these two, let’s take a step back and examine the purpose of progress notes in the context of mental health.
A clinician (such as a psychologist) takes these notes during a session with a patient. They will, in general, be related to the treatment plan, as well as notes of pertinent episodes that occur during the treatment session. Specific information regarding treatments and responses should be included.
As such, mental health progress notes should not contain your own feelings or judgments, but rather should describe the clinician’s actions, the client’s answers, and the observed change (the results of the interventions and responses).
In many circumstances, progress notes will be shared with other professionals collaborating with a patient’s treatment plan. As a result, they play a critical role in communicating information including current patient care, treatment plans, and medical history so that other healthcare professionals don’t have to start from scratch every time they meet with a new patient.
The abbreviation DAP stands for Data, Assessment, and Plan. It’s a straightforward and thorough template for keeping track of your notes.
DAP notes are a way to keep track of progress and are part of the client’s file, that may be shared with the client and third parties upon request. Under the Data portion of DAP notes, subjective and objective observations are combined.
Many therapists prefer this strategy because it is more suited to the subjectivity of behavioral health. DARP notes are the result of some practitioners adding an additional Response section. The client’s response to a session is noted in the Assessment portion of DAP notes.
Patient Presentation, Safety Issues, Interventions, Goals, and Objectives are examples of DAP Notes. Unless the therapist is working in a medical setting where case notes must be shared, the Standard Progress Note format may be more appealing and simpler to utilize.
It’s critical to remember that a DAP letter is a progress note, not a note for personal psychotherapy. This indicates it’s part of the official record and can be shared. Let’s take a closer look at each section of the DAP note:
Everything you heard and saw at the session is included in the data component of DAP notes. It is a summary of all the data gathered. The majority of this data comes from client self-report, but clinical observations are also useful.
Despite the fact that the majority of the data will be objective, the doctor may add some subjectivity to the process at times. They might write down that a client “appears agitated,” for example. “What did I see?” is a broad question that encapsulates this section.
The DAP note’s assessment section represents the clinician’s interpretation. In the assessment portion, there are a few key questions to answer: Is the client attempting to resolve their issues? What evidence does the data show that they are paying attention to their treatment goals?
Is there any progress being made? Is there a specific diagnostic or issue that needs to be addressed based on the data? “What does the data mean?” to put it another way.
The plan for future therapy is the last section of the DAP note. It could include both what you want the client to do next and what you want to accomplish as a therapist.
For example, you may indicate that the client has a school assignment or that you need to speak with their psychiatrist about their prescription. Keep in mind that this is only a portion of the treatment plan.
Also Read: Behavioral Health vs Mental Health
When working with patients or clients, medical and psychological professionals frequently use SOAP notes. They’re an easy-to-understand method of documenting key moments during a conversation. Coaches can also use SOAP notes with minor modifications.
Only critical and pertinent information is provided in SOAP notes, which are structured and ordered in this manner. These notes, which were first produced 50 years ago by Larry Weed, give a foundation for analyzing information and a cognitive framework for clinical reasoning.
SOAP notes are typically used by medical professionals, but as you read on, you’ll see examples of how you might alter them for use in a coaching session.
To begin, the term SOAP stands for the components listed below:
The client or patient communicates their main problem in the early half of the engagement. It is the professional’s responsibility to listen and ask clarifying questions if there is more than one. These questions aid in the accurate writing of the subjective and objective aspects of the notes.
The term ‘subjective’ refers to the client’s perspective on their feelings and experiences. It could also include the perspectives of individuals close to the client.
In this area, the professional only includes information that is observable. Details concerning vital signs, physical exam findings, laboratory data, imaging results, other diagnostic data, and recognition and review of other practitioners’ documentation may be included in a clinical environment.
In this portion, the professional brings together what they’ve learned from both subjective and objective data. The therapist or doctor will identify the primary issue as well as any contributing variables.
The plan is where the rubber meets the road. The doctor develops a future plan in collaboration with the client or patient. Additional testing, drugs, and the introduction of other activities could all be part of the plan (e.g., counseling, therapy, dietary and exercise changes, meditation.)
It’s helpful to know what perfection looks like to you when you’re composing your notes. Yes, your notes will not be flawless, because no note is, but you must first comprehend the desired outcome in order to determine if you came near.
After you’ve decided to utilize this strategy, you’ll need to modify that information to your specific requirements. Consider the following question: What information do I require about my patient and this session in order to construct a strategy for them? What information would I find useful and useful if these notes were written by someone else?
You want to gather as much useful information as possible from your notes, but you don’t want to make them too complicated. Begin by familiarizing yourself with the information you don’t want to put in your notes and the information you do.
You don’t have to record that you changed the temperature as soon as your patient walked in, but you might want to take note of their demeanor as they greeted you. What you don’t want is a page full of terms that appear comprehensive but can’t be used. This may take some time to master, but it’ll be a habit you’ll be glad you created.
Another aspect of the procedure to consider is the type of note-taking device you’ll use. Is it more efficient for you to take notes using an online template or would you rather write your notes on paper and then upload them online?
When determining which option is ideal for you, keep in mind the end outcome you want to achieve. Do you have sloppy, difficult-to-understand handwritten notes? Do you ever feel like you can’t type as quickly as you believe you can? You may need to experiment with both for a while before deciding which strategy to utilize in the future.
If you pay attention to tense, minimize pronoun confusion, and complete a simple spell-check, your notes will be easier to follow and you will come across better (if the notes are electronic).
Put quotation marks around your client’s precise words if you’re quoting them. After that, double-check the dates and times of occurrences, as well as the spelling of names.
Even if you triple-check your work, mistakes happen, and it’s not the end of the world. What matters is how you remedy those mistakes. If you’re using conventional (manual) note-taking, avoid using scratch-outs, an eraser, or correction fluid to change records. Any omissions or deletions may cause the person reading the notes to be suspicious.
You’ll need to figure out the best time to jot down your progress notes. It’s neither practicable nor helpful for most mental health providers to do them while in session with their clients.
Rather than taking notes during the session, you should take personal notes that you can later utilize to complete the SOAP framework. However, you must strike a balance; you do not want to wait too long.
Avoid using informal language, colloquialisms, non-standard abbreviations, or slang in your notes, as these can detract from their professional tone. A professional tone will increase the power of your notes while also ensuring that they are clear enough for others to review.
When possible, avoid using wordy phrasing in your notes because it makes them more difficult to grasp, especially for another expert doing a short review of the session.
Your SOAP notes for mental health sessions must be free of judgment in order to maintain an objective perspective. Rather than making baseless comments without evidence, they should accurately depict events that provide insight into the client’s behavior.
Removing adjectives like “extremely” and “a lot” from your note-taking will compel you to explain the client’s behavior rather than making assumptions about their mental state.
Keep in mind that your therapy notes will be read and reviewed by others. It is critical to be aware of this reality. Stick to standard vocabulary and grammar instead of using shorthand, jargon, or your own unique acronyms.
This will aid with the understanding of your notes by all members of your team, allowing you to more effectively assist the patient in his or her rehabilitation.
Because therapy notes are intended to chronicle a patient’s development and be shared throughout the patient lifecycle, it’s critical to maintain a professional demeanor when recording your observations.
Therapy notes should be brief but comprehensive enough to provide others with a clear picture of what happened. It’s critical to keep to the facts while presenting evidence to back them up.
The greatest way to enhance your note-taking abilities and avoid the issues that might diminish the quality of a health professional’s notes is to use electronic mental health progress notes.
By using electronic health progress notes, you’ll be well on your way to making notes that are clear, concise, and useful for you, your patient, and other physicians if you keep these guidelines in mind.
If you are a mental health practice owner who is having trouble managing note-taking, going for electronic notes may be the right thing to do. Because of the risks connected with poor or inadequate progress reports, all mental health clinicians must be on top of their game in this area.