DAP Notes in Therapy: Format, Examples and Templates

• A DAP note has three sections: Data covers what happened during the session, including interventions used. Assessment documents your clinical judgment, including the client’s progress toward treatment goals. Plan outlines next steps.¹
• Payers set documentation requirements but don’t necessarily require specific note headings. In a federal audit of Medicare psychotherapy, missing session time was the most common error, appearing on 60 of 216 sampled days.²
• EHR platforms vary in how they handle DAP notes. SimplePractice includes a pre-built DAP Note template with its Essential (79/month)andPlus(99/month) plans, while Upheal and TherapyNotes offer AI tools that can generate DAP notes.

DAP Notes have a three-part format and are written after a session is completed. The note contains both the client’s report and the clinician’s observations together. It also informs payers and auditors of session time, interventions, as well as the client response and progress alongside the treatment plan. DAP notes are a popular format used by clinicians. In fact, Nevada’s children’s mental health services adopted DAP as their required charting model in 2008. Due to this many EHR platforms, like SimplePractice, include a pre-built DAP template.

See SimplePractice’s DAP Note template and plans

This article is for information only and is not medical or legal advice. Documentation rules vary by state, license and payer.

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What is a Therapy Note?

A therapy note is a record the clinician keeps about what happens during a session. They are required to be completed for each session. For example: Blue Cross Blue Shield of Michigan requires a progress note for every session.³

HIPAA currently recognizes two different kinds:

1. Progress notes: These are the notes clinicians document in a client’s medical record. They summarize the session, symptoms, interventions, treatment goals, and progress. DAP notes fall into this category.
2. Psychotherapy notes: These are a clinician’s private notes documenting or analyzing the contents of a counseling conversation. Under HIPAA, they are kept separately from the medical record and receive additional privacy protections.⁴

You can find the federal definition of psychotherapy notes in 45 CFR 164.50. While it excludes session times, modalities, test results and summaries of diagnosis, symptoms, treatment plan and progress. Those items make up most of a DAP note’s content.⁴

Helpful Note: Some clinicians and payers call psychotherapy notes process notes.

For more information about client access and record retention you can visit our SOAP notes for therapy guide. The therapy progress notes cheat sheet sorts which details belong in the chart.

How to Write A DAP Note

Both Nevada’s Policy and Simple Practice’s DAP guide put the session facts under the Data section. The clinicians judgement goes under Assessment and then the next steps fall under Plan.¹

Data

Data is the factual record of the session. Nevada encourages clinicians to put the client’s own words here alongside observed affect, mood, and appearance.⁵

It typically covers:

• The reason for the visit, who attended, the service type, and location
• Appearance, mood, affect, and mental status
• Symptoms or events the client reports since the last session
• Homework reviewed and any screening results
• Interventions and the client’s response

Assessment

The Assessment section is where you use your clinical judgment to interpret the information in Data. It covers how the client is responding to treatment, their progress toward treatment goals, and any changes in symptoms, diagnosis, or other concerns.⁶ Nevada also includes working hypotheses and the client’s response to the treatment plan.⁵ Many clinicians include a risk assessment here, too. Your conclusions should be supported by the information documented in Data.

Many clinicians find Assessment the hardest part of a DAP note to write. Insurers often look for progress toward treatment goals, ongoing symptoms, barriers to progress, risk, and medical necessity.

Plan

The Plan section outlines what happens next, including the next session’s date, time, and location, any homework or referrals, consultations, and changes to the treatment plan.⁶ Nevada also recommends documenting which treatment goals were addressed and whether medical necessity has changed.⁵

DAP Note Examples: Individual, Couples, Telehealth, And Group Notes

These four sample notes are fictional examples of the format and each include the items payers ask for in that session type. These are only examples and are not direct clinical guidance.

Individual Session

Client: “T.” (fictional adult)

Date of service: [date]

Service: 90837 individual psychotherapy, office

Clock time: 9:00 to 9:55 am, 55 minutes

Diagnosis: [ICD-10]

D: Session 9. Checks pulse and searches symptoms online about 2 hours a day (4 at intake). Anxiety scale 11, intake 16. Did 4 of 5 exposure tasks; skipped the clinic waiting room. Affect tense, then calmer. Role-played turning down reassurance; urge to check fell from 8/10 to 5/10.

A: Steady progress on Goal 2 (less checking and reassurance seeking). Avoiding medical settings is the main barrier. Denied thoughts of harm to self or others. Symptoms remain above target; weekly care continues.

P: Next session [date], 9:00 am. Homework: waiting-room exposure, two set checking times a day. With signed consent, update primary care doctor.

Signed: [name, credentials] [date signed]

Couples Session

Clients: “L.” (fictional adult, identified patient) and spouse “K.”

Date of service: [date]

Service: 90847 family psychotherapy, patient present, office

Clock time: 5:00 to 5:50 pm, 50 minutes

Diagnosis: [L.’s ICD-10]

Present: L. and K., whole session

D: Focus: L.’s alcohol use disorder. L. reports 41 days without drinking and two cravings, both on Friday evenings. K. asks daily whether he drank; L.: “It makes me feel watched.” Coached K. to trade daily questions for a weekly check-in; both rehearsed it and agreed to try.

A: Progress on L.’s Goal 1 (abstinence) and Goal 3 (family support for relapse prevention). L. says the daily questions start arguments, which he sees as a relapse risk. Neither reported safety concerns; L. denied self-harm thoughts.

P: Sunday check-ins at home; L. keeps individual sessions. Next joint session [date]. Review Goal 3 in four weeks.

Signed: [name, credentials] [date signed]

Telehealth Session

Client: “N.” (fictional adult)

Date of service: [date]

Service: 90834 individual psychotherapy, audio only, modifier 93 Client at home (POS 10); clinician video-capable. Client declined video today: no private room.

Clock time: 7:30 to 8:15 pm, 45 minutes

Diagnosis: [ICD-10]

D: Session 5, insomnia-focused CBT. Diary: about 5.5 hours of sleep a night; falls asleep in 35 minutes (70 at start). Kept rise time 6 of 7 days, napped twice. “My routine slips on weekends.” Reviewed diary, widened sleep window by 15 minutes, planned for weekend naps.

A: Progress on Goal 1 (asleep within 30 minutes most nights). Naps are slowing progress. Denied self-harm thoughts. Appearance not observable.

P: No naps, daily diary. Next session [date] by video if a private room is available, otherwise audio only with the reason noted.

Signed: [name, credentials] [date signed]

Group Session

GROUP SECTION (same in every member’s chart, no names)

Service: 90853 group psychotherapy, office

Date: [date] Clock time: 6:00 to 7:30 pm, 90 minutes

Members present: 7

Emotion regulation skills, week 4 of 10. Taught urge surfing.

MEMBER SECTION: “P.” (fictional adult) Diagnosis: [ICD-10] D: Present throughout. Used a grounding skill twice this week instead of leaving work early. Urge rating 7/10 before practice, 4/10 after. Quiet in the full group, active in pairs.

A: Progress on Goal 1 (use a skill before acting on urges). Speaking up in the group is still hard. Denied self-harm thoughts.

P: Weekly group; next session [date]. One urge-surfing log entry a day.

Signed: [name, credentials] [date signed]

DAP vs SOAP Notes

SOAP stands for Subjective, Objective, Assessment, and Plan. DAP combines the first two headings (subjective and objective) into one section called Data. Both formats end with an Assessment and Plan sections.

SimplePractice says the merge helps clinicians complete notes faster and Upheal adds that a SOAP notes objective section often only holds physical presentation and assessment results.⁶

See SimplePractice’s pre-built DAP and SOAP templates

Payer and Auditor DAP Requirements

Payers and auditors review notes for specific information to provide reimbursement. Medicare currently has no national documentation standard for psychotherapy and the HHS Office of Inspector General (OIG) found requirements vary between its claims contractors 6; however, some spaces share the same basic items. For example: Medicare contracts, BCBS Michigan, and Medicaid plans often ask for the same items.⁷⁸³⁹

The session length determines the billing code that will be used. For example: sessions lasting 38–52 minutes use code 90834, while sessions lasting 53 minutes or longer use 90837.4

Family and group sessions have a few additional requirements. For example: Medicare contractor Novitas only covers family therapy when it focuses on the patient’s own condition. For group therapy, one shared note can be used as long as it doesn’t identify other members, but each patient still needs their own entry. Novitas also limits groups to 10 participants.⁸ BCBS Michigan requires family therapy notes to identify each person’s relationship to the patient and expects group sessions to include 4–12 members.³

For telehealth, notes should match the billing claim and contain any required modifiers. For Medicare, this means using place of service code 02 or 10, along with modifier 95 for video sessions or 93 for audio-only sessions.¹⁰ Audio-only sessions are allowed when the client can’t use video or doesn’t consent to it, as long as the clinician is able to provide video visits.¹¹

Medicare reviewers can’t request separate psychotherapy notes, so the records submitted for review, including DAP notes, need to show medical necessity. If the documentation doesn’t support the need for treatment, the claim can be denied.¹²

Common Documentation Mistakes

The OIG reviewed Medicare psychotherapy claims from March 2020 through February 2021 and estimated that $580 million of $1 billion in payments was improper, including $348 million related to telehealth.² Findings from that audit and other payer reviews highlight several common documentation issues:

• Missing session time: Session time was missing on 60 of the 216 sampled days, making it the most common error in the OIG audit.²
• Poor connection to the treatment plan: Treatment plans were incomplete or missing on 43 sampled days.² Optum Maryland’s third-quarter 2024 Medicaid audits also found low scores for documenting progress toward treatment goals, ranging from 5% to 67% across provider types. Scores below 85% trigger an improvement plan.⁹
• Missing risk assessments: Optum Maryland’s scores for ongoing risk assessment documentation ranged from 25% to 100%.⁹
• Missing signatures: The OIG found that 31 sampled days had notes without a signature.²
• Cloned notes: Copying the same language across sessions can raise concerns about whether the documentation supports medical necessity. Medicare contractors have warned that cloned notes may lead to recoupment if they misrepresent the services provided.¹
• Improper corrections: Changes to existing documentation should include a visible date and identify who made the correction.¹²

DAP Note Templates Available in EHRs

While SimplePractice, Upheal, TherapyNotes, Jane, and Healthie all support SOAP notes only SimplePractice, Upheaval, and TherapyNotes also offer a DAP template. Details below are as of October 18, 2026.

SimplePractice

SimplePractice offers two pre-built DAP templates: DAP Note with Suicide Risk Assessment or DAP. To add one, go to Settings > Documentation > Template Library > Browse Pre-Built Templates > + Add.

Pre-built templates and template editing require the Essential or Plus plan. The $49 Starter plan includes intake forms and scored measures but not these features. Group appointments are available only on Plus. SimplePractice also offers a 30-day free trial of Plus, with no credit card required.

Using DAP with AI Note Taker

SimplePractice’s AI Note Taker costs an additional $35 per month and doesn’t have a dedicated DAP setting. It drafts a biopsychosocial assessment and SOAP note for the first visit, a SOAP note for the second, and then uses the note type from your most recent session.

To switch to DAP, edit the latest Note Taker draft into a DAP note. SimplePractice says subsequent drafts will adapt to that change. You can also provide instructions to refine a draft, although its sample instruction uses SOAP. Review every AI-generated note before saving.

With Note Taker added, the Essential plan costs $114 per month and Plus costs $134 per month.

For more on features, billing, scheduling, and telehealth, see our SimplePractice review.

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Other EHRs With DAP Documentation Options

Other platforms vary in how they support DAP notes, particularly when AI documentation or group sessions are involved.

• Upheal: Offers DAP as an AI note type for individual and couples sessions.
• TherapyNotes: Of these five platforms, it’s the only one whose public guides document a DAP workflow for group therapy. Its Group Note wizard captures shared content once and generates a separate DAP note for each attendee.
• Jane: Its AI Scribe prompt defaults to SOAP, but you can rewrite the prompt to request DAP.
• Healthie: Lets you build your own form or, on a paid plan, ask its team to create one for you.

For a broader comparison of features and pricing, see our SimplePractice alternatives guide.

Compare SimplePractice plans with DAP templates