Data

[Data narrative] (Write one coherent paragraph in the encounter’s natural order. Include only what was explicitly spoken by the patient or clinician or directly observed and stated aloud. Cover, when stated: primary reason for today’s visit; interval course since last visit; frequency/duration/severity; triggers/contexts and relieving/exacerbating factors; self-management attempts; concrete impact on functioning at home/work/school; safety content in the patient’s words when quoted—e.g., suicidal or violent thoughts, access to means, recent crises, protective factors; brief clinician observations or MSE elements only if spoken; specific interventions performed today and the client’s in-session response; standardized measures with exact names/scores if named; collateral or records discussed; care setting/telehealth modality and who was present. Do not infer or solicit content not spoken.)

Assessment

(Summarize only the clinician’s explicit impressions stated during the encounter. Do not add patient-reported data here. Do not infer diagnoses or risk.)

[Problem 1]: [Working impression or diagnosis] (One concise paragraph: linkage between stated symptoms/function and the impression; response to current interventions as stated; progress toward goals if stated; current risk level only if stated; differentials only if stated.)

[Problem 2]: [Working impression or diagnosis] (Include only if an additional issue was explicitly discussed. Summarize as above.)

Plan

(Document next steps exactly as the clinician states them. Keep to actionable items. Do not infer content.)

[Interventions to continue or initiate] (Short bullets in spoken order.)
[Between-session tasks or homework] (Only if stated; include frequency/duration if spoken.)
[Risk mitigation steps] (Only if stated; e.g., safety plan updates, means restriction, crisis resources.)
[Care coordination or referrals] (Only if stated; include purpose and parties.)
[Medication considerations] (Only if stated; changes, monitoring, side effects, or prescriber coordination.)
[Follow-up] (Only if stated; timing and contingencies.)

(Leave sections blank if not available. Do not include billing codes or payer-specific language.)

Specialties

DAP Note (Therapy)

Specialties

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