Progress notes…in the helping field we certainly do hear that term a lot. Therapists everywhere rely on progress notes to record and manage client records as service unfolds. Every session, from one to the next, reveals client challenges and progress. Documenting progress notes help monitor the details of these sessions, help collect clinical information, and highlight those challenges and/or progress seen in treatment, ultimately paving the direction of future treatment. Reality is that therapists will have multiple clients in a day, in which progress notes help keep information current, individualized, and organized.
Sometimes unknown, is the fact that there are different formats that can be used to structure progress notes. Three, best practice, progress note formats, may vary depending on your region, include the DAP (Data, Assessment, Plan), the SOAP (Subjective, Objective, Assessment, and Plan) and the BIRP (Behavior, Intervention, Response and Plan).
Regardless of which format is used the progress note should still capture key elements; 1) Important gathered information about presenting problem or behaviors, 2) Assessment inclusive of your professional opinion regarding how the session went or your interpretation, techniques and methods used during the session, and the responses received to the therapy as a whole, and 3) Addressing the next objectives.
As such, these various progress note formats are aimed to help professionals in the field monitor the progress of their clients in an efficient and effective fashion. It is a tool designed to help reduce time spent on documentation. It can also aid in facilitating communication with all other involved providers and yield valuable insight for collaboration purposes. Which is why it is also important to remember progress notes are a part of the client’s official record and subject to be shared/viewed by others.
Progress Note Documentation Method:
The progress note documentation method can be broken down into three or four sections dependent upon the format being used. Today, we are going to focus on the DAP format, we will look at the SOAP and BIRP formats at another time.
The DAP uses three boxes:
Data
The data section of the progress notes is the objective recollection of the session. This is where you capture information that was gathered, as well as, everything that was observed and heard during the session. This section should be used to capture information like behavior, dispositions, and responses. Though primarily objective, subjective recollection is at times seen when referencing observations of behaviors. For example: “Client appeared irritated when asked about a sensitive topic.” (subjective) versus “Client reacted to a sensitive topic by tapping their foot.” (objective)
A good rule for this section is to ask yourself: What did I observe?
Assessment
In the assessment section of the progress note you’ll want to assess and interpret the data section and provide a subjective interpretation. Here you are documenting your professional opinion about how the sent went. Your assessment of the client’s progress and response to treatment. This is critical to understanding the client’s progress toward the goal and future treatment plan decisions.
Questions to consider may include: Is the client making efforts towards achieving goals? Is the client engaged in treatment? What does the data mean?
Plan
The plan is the section that connects one session to the next. In this section you’ll want to identify what is to be worked on, by you and/or the client, from now into the next session. At times, a “homework assignment” may be given for the client to work on in-between sessions. In addition, next session objectives are identified. It is also at times helpful to set a date and time of the next session appointment.
A question to consider is: What will be worked on next?
