Creating a DAP Note

Who this is for

• Providers using the EMR
• Organization-based staff scheduling and documenting billable client sessions

Overview

A DAP note is created and attached to a specific appointment, documenting the Data, Assessment, and Plan for that session. During the appointment, providers are encouraged to review the client's Individual Recovery Plan and add progress notes that reflect how the session connects to it.

Complete the DAP Note

After meeting with your client, complete all three parts of the DAP note:

1. Data — Document what happened during the session. Include subjective details (what the client shared in their own words, how they described their feelings) and objective details (what you observed, such as behavior, mood, or participation). Focus on facts and observations, not interpretations.
2. Assessment — Based on the data, describe how the client appears to be doing. Note any progress, challenges, or patterns you observed. Focus on understanding and supporting the client, not diagnosing.
3. Plan — Outline the next steps. Include what you and the client agreed to work on, any resources or support shared, and any follow-up actions. Note how the client responded to the plan (e.g., motivated, unsure, encouraged, or had concerns).
4. Click Save. This does not submit your notes to billing — save your progress as you go.

Update the Individual Recovery Plan (IRP) Goals

In addition to the DAP note, document any progress the client has made toward their IRP goals. For a client's first appointment, the IRP will include the following Basic Needs goals:

• Food
• Clothing
• Shelter
• Technology/Phone

Additional goals can be added to the IRP at any time.

To add a progress note to a goal:

1. Click on a goal in the IRP section to expand the Progress Note area.
2. Add a progress note tied to that goal.
3. If the client has completed the goal, add a progress note and check Mark Goal Completed.
4. Click Save. This does not submit your notes to billing — save your progress as you go.

Submit your Documentation

Once your DAP note and IRP progress notes are complete and saved, you're ready to submit.

Click the submission button at the bottom of the page — the label will vary depending on the appointment type:

• Billable appointments: Submit to Billing
• Non-billable appointments: Mark as Completed

A dialog box will appear confirming the program, start time, and end time of the appointment. Review the details, then check the box to certify the accuracy and validity of the session before clicking Submit or Completed.