Whether you're a therapist, social worker, or psychiatrist, taking clear, concise, and accurate notes is essential for continuity of care, legal compliance, and professional communication.
Two of the most common types of progress notes used in mental health settings are SOAP notes and DAP notes. While both serve similar purposes—recording a client's progress and treatment—they follow different structures and conventions.
In this article, we will explain the key differences between these two note-taking methods, guide you on how to write effective SOAP and DAP notes, and help you decide which format to use in different clinical contexts.
SOAP Notes: What They Are and When to Use Them
SOAP stands for Subjective, Objective, Assessment, and Plan. This format is widely used across medical and therapeutic settings. SOAP notes allow therapists to systematically document a client’s condition and progress, making them ideal for comprehensive, structured reporting.
1. Subjective (S):
What it is: This section captures the client’s reported symptoms, thoughts, feelings, and experiences. It’s based on the client's own words and perception of their progress.
How to write it: Focus on the client's feelings, concerns, and any changes they report in their mental state or behaviors.
Example: “Client reports feeling more anxious this week, stating, ‘I can't stop worrying about my job performance.’”
Why it matters: This gives context to the therapist's understanding of the client’s condition and serves as a baseline for comparison in future sessions.
2. Objective (O):
What it is: This section is for observable facts, such as the client’s behaviors, mood, appearance, or any measurable data (like test scores or physiological indicators).
How to write it: Include things you can directly observe or assess.
Examples: “Client was well-groomed,” “Mood was anxious, as noted by fidgeting,” or “Client scored 14 on the Beck Depression Inventory.”
Why it matters: These objective observations can be used to track the client’s progress over time and to add objectivity to subjective reports.
3. Assessment (A):
What it is: This is where the therapist provides a clinical interpretation of the information presented in the subjective and objective sections. This might include diagnoses, treatment progress, or clinical impressions.
How to write it: Summarize the client's self-reported state and your objective observations.
Example: “Client appears to be experiencing moderate anxiety, possibly exacerbated by reported stress at work. Symptoms align with generalized anxiety disorder (GAD).”
Why it matters: The assessment connects the dots between the client’s subjective experience and the objective data, allowing the therapist to evaluate progress and identify next steps in treatment.
4. Plan (P):
What it is: The plan section details the treatment interventions for the next session or period. This can include therapeutic techniques to be used, goals for the client, or referrals if needed.
How to write it: Be specific!
Example: “Continue cognitive-behavioral therapy (CBT) focusing on stress management techniques,” or “Refer to psychiatrist for medication evaluation.”
Why it matters: The plan section provides a roadmap for future treatment, ensuring continuity of care and focus on treatment goals.
DAP Notes: What They Are and When to Use Them
DAP stands for Data, Assessment, and Plan. While similar to SOAP notes, DAP notes tend to be a bit more streamlined and less structured, which some therapists prefer for efficiency and flexibility.
1. Data (D):
What it is: The Data section combines the Subjective and Objective parts of the SOAP format. This is where the therapist documents both the client’s reported experiences and any observable facts.
How to write it: Include both what the client said and what you observed.
Example: “Client states feeling overwhelmed with work and reports sleeping poorly. Appears fatigued with a tense posture.”
Why it matters: It provides a well-rounded picture of the client’s current state, combining subjective complaints with observable signs.
2. Assessment (A):
What it is: In this section, the therapist gives a clinical interpretation or diagnosis based on the data. The assessment could address the client’s progress, challenges, or evolving needs.
How to write it: Use the Data section to inform your assessment.
Example: “Client’s anxiety seems to be increasing in response to work-related stress. She reports feeling helpless and unsure of how to cope with daily demands.”
Why it matters: This analysis of the data helps guide treatment decisions and reflects the therapist’s clinical judgment.
3. Plan (P):
What it is: Similar to the SOAP format, the Plan section outlines the next steps for treatment, interventions, and client goals.
How to write it: Be clear and action-oriented.
Examples: “Continue exploring coping strategies for stress management” or “Client will journal daily to track anxious thoughts.”
Why it matters: The plan provides direction for the next treatment phase and ensures that the client’s needs are addressed.
Key Differences Between SOAP and DAP Notes
Structure: SOAP notes are more structured, with separate sections for subjective and objective information. DAP notes combine these two into the "Data" section, making them slightly more concise.
Focus on subjectivity vs. objectivity: SOAP notes clearly distinguish between what the client reports (subjective) and what is observed (objective). DAP notes merge these into a single “Data” section, which can be more efficient but may provide less granularity.
Context of use: SOAP notes are often used in medical settings, where clear distinctions between subjective and objective information are essential for communicating with other healthcare providers. DAP notes are often used in therapy settings where the focus is on the therapeutic process and may involve fewer formal observations.
Flexibility: DAP notes are more flexible and can be used in a wider variety of settings. They might feel less formal or rigid than SOAP notes, which is why some therapists prefer them for routine progress notes.
When to Use SOAP vs. DAP Notes
The choice between SOAP and DAP notes often depends on your personal preference, the setting in which you work, and the specific needs of your documentation.
SOAP notes are ideal in situations that require detailed documentation, such as:
Comprehensive assessments: When an in-depth understanding of the client’s history, current condition, and progress is required.
Formal or legal settings: SOAP notes can provide a clear and structured record that is useful for third-party review, insurance purposes, or in legal contexts.
Multidisciplinary care: In situations where medical professionals may need to review the notes (e.g., inpatient settings, integrated care settings).
DAP notes are often used in less formal or more time-sensitive contexts, such as:
Routine therapy sessions: When the focus is more on the client’s narrative and emotional state than on strict clinical observations.
Ongoing clients: For clients who are stable or progressing steadily, DAP notes offer an efficient way to document treatment without overloading on details.
Community-based or outreach settings: When you require a more streamlined, flexible format that is efficient but still provides enough information to inform decision-making.
Tips for Writing Effective SOAP and DAP Notes
Be specific: Avoid vague statements like “Client feels bad” or “Client did well.” Describe specific emotions, behaviors, and observations — for example, “Client reported feeling anxious during the session and expressed difficulty concentrating at work.”
Use clear, professional language: Avoid jargon or overly technical terms that may be unclear to other professionals reviewing your notes. Write in a way that’s professional, concise, and accessible.
Document progress regularly: Both SOAP and DAP notes should reflect changes over time. Document what worked well and what didn’t in order to track the client’s progress toward treatment goals.
Be objective and neutral: Avoid subjective judgments or personal biases, especially in the "Assessment" section of both note structures. Stick to clinical observations and facts.
Ensure confidentiality: Make sure the documentation, storage, and sharing of notes are compliant with HIPAA guidelines and respect the client’s privacy.
Regardless of the note taking method you decide on, both SOAP notes and DAP notes offer valuable structures for documenting mental health treatment. Understanding when to use each format will help mental health professionals maintain comprehensive records that support effective treatment planning, progress tracking, and legal or regulatory compliance.
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