![]() ![]() ![]() What you want to avoid is a bunch of words on the page that look thorough but ultimately can’t be used. 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. Start getting familiar with the information you don’t want to include in your notes and the information you need to include. You want to get as much valuable information from your notes as possible, but you don’t want to overcomplicate them. What matters is that each section allows you to use the information contained there in a quick and effective manner. 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. 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?Īfter you’ve answered these questions for yourself you can begin to determine how each section of your therapy notes should look. 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. 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. When writing your notes, it helps to understand what perfection looks like to you. It’s simple enough, right? Of course, you want to use the technique in a way that’s beneficial to you. 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. This is the final piece of your note-taking puzzle. What do you think that action or actions mean? Essentially, you’ve collected your data and now you need to analyze it. This could be any relevant behavior, especially those that might affect the way you proceed with treatment.Īfter you’ve recorded the relevant behaviors, you’ll use this section to understand what those behaviors mean. When writing in this section you’ll want to take note of what you observed during the session. ![]() The first step in writing DAP notes is understanding the format. 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. Many clinicians have found that using DAP notes is the best way to take notes in a quick, useful, and effective manner. Creating effective notes for your therapy sessions doesn’t have to be a daunting task. ![]()
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