⚖️How to structure your therapy notes?

This is Part 2 in the Note Taking series. Read Part 1 on What Purpose Should Psychotherapy Notes Serve? Next week, I will share thoughts on when to write your notes.

You’ve identified what purpose you’d like for your notes to serve, how do you structure the information? Formats can be helpful to get started. These can be further personalised based on your approach and requirements.

SOAP and DAP are two of the most common formats.

• Session Content: The difference between both is how they organise session content. SOAP divides it into subjective statements about how the client is doing and objective data which is measurable such as scores on a self-rating scale. DAP clubs both into one.

• Assessment: This moves beyond session content to capture the therapist’s observations and reflections about the therapeutic work. This can be details of transference/countertransference, feelings that were evoked within you during the session, analysis of how therapy is progressing etc.

• Plan: For noting details about the treatment plan in the future.

To read more about the two formats and detailed ideas about what the ‘Assessment’ section can capture, download this short read.

Until next week,
Suvrita

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