DAP NOTE — ADULT OUTPATIENT MENTAL HEALTH

ENCOUNTER
Client identifier:
Service date, type, setting and participants:
Actual start/stop times and service duration, as required:
Entry date/time:
Author name, credentials and authentication date/time:
Current assessment/problem and treatment-plan reference:
Goal/objective addressed and baseline:

D — DATA
Client report and period covered:
Other information sources, dates and relevant permission:
Relevant observations and assessment findings:
Intervention delivered, including help or adaptations:
Client response, including activities declined:
Safety inquiry/findings/actions actually completed; identify unassessed areas:

A — ASSESSMENT
Clinical interpretation supported by Data:
Progress against the objective and comparison period:
Barriers, uncertainty and reason for the next decision:

P — PLAN
Agreed client action and timeframe:
Clinician action, owner and review checkpoint:
Continue/change/stop decision and agreement:
Next appointment: confirmed details or outstanding scheduling:
Referral/consultation: actual status, owner and follow-up:

BEFORE SIGNING
[ ] Correct encounter, service, times and author.
[ ] Reports and observations have identifiable sources.
[ ] Intervention and response describe what happened.
[ ] Assessment is supported; progress matches the measure.
[ ] Unknown or unassessed findings are not recorded as normal.
[ ] Each next step has an owner, timeframe and accurate status.
[ ] Narrative and structured fields meet applicable payer requirements.
[ ] Authentication and any amendment preserve the record history.