DAP Note Examples by Diagnosis (Depression, Anxiety, PTSD)

A DAP note has three parts. Data is what happened in the session, both what the client said and what you observed. Assessment is your clinical read on it. Plan is what happens next. It is the behavioral-health field's leaner take on the four-section SOAP note, and below you'll find worked examples for depression, anxiety, PTSD, and substance use disorder that you can copy as templates. Every example here is illustrative, written to show structure. None of them is a real patient.

A blank format guide only gets you so far. What you actually want, sitting down after a session, is a note that looks like the one you're trying to write, for the kind of presentation you just saw. So this is built as a set of diagnosis-specific samples, not a definition you have to translate yourself. Read the structure once, then jump to the example that matches your caseload.

Key takeaways

• DAP = Data, Assessment, Plan. It merges SOAP's Subjective and Objective into one Data section, so a session reads as one narrative instead of two boxes.
• Data is description; Assessment is judgment. The diagnosis and your reasoning live in Assessment, against the DSM-5-TR.
• The 4 examples below (depression, anxiety, PTSD, SUD) are illustrative clinician-style samples, not real patient records.
• Documentation load in behavioral health is heavy: a 2023 National Council survey of 750 workers found 93% reported burnout, and 68% of those in direct care said admin time eats into client time.

What is a DAP note, and what goes in each section?

DAP stands for Data, Assessment, and Plan. It's a progress-note format used widely across therapy, counseling, and behavioral-health work, and the appeal is that it fits how a session actually goes.

Here's the split, section by section.

Data is everything observable from the session. What the client reported in their own words, their mood and affect, behaviors you watched, symptoms, screener results, and the interventions you used. It's description, not interpretation. The test is one line: if it's a fact about what happened, it's Data.

Assessment is your clinical judgment about that data. The working diagnosis, progress toward goals, changes in symptoms or risk, and the reasoning that connects what you saw to what you think. This is the section that carries the medical necessity of the visit, and it's the one a model finds hardest, because it's reasoning, not transcription.

Plan is what happens next. Interventions for the next session, homework, medication or referral steps, the follow-up interval, and any safety planning. A dropped Plan item is a missed action, so completeness matters here more than polish.

How is a DAP note different from a SOAP note?

The short version: SOAP has four sections, DAP has three, and the missing one is a merge, not a cut.

SOAP, per the StatPearls reference, uses four headings: Subjective, Objective, Assessment, and Plan. The Assessment there is described as "the synthesis of subjective and objective evidence to arrive at a diagnosis," and the Plan covers further testing and referrals. DAP keeps Assessment and Plan unchanged and folds Subjective and Objective together into a single Data section.

Why therapists tend to reach for DAP: a talk-therapy session isn't a physical exam. There's no clean line between what the client "subjectively" reported and what you "objectively" measured, the way there is between a chief complaint and a blood pressure reading. Most of a session is conversation, observed and described together. One Data section captures that as a single narrative instead of forcing you to split a sentence in half. If you want the full anatomy of the four-section format and a rubric for grading any note, our SOAP note quality guide covers it.

That's the whole difference. Same clinical logic, one fewer box. Now the part you came for.

DAP note example: depression

Illustrative sample. Not a real patient. A 30-minute follow-up for an adult with major depressive disorder, four sessions in.

Data: Client attended on time, alert, mildly disheveled. Reported mood as "flat, maybe a 3 out of 10" over the past two weeks, with low energy, early-morning waking around 4 a.m., and reduced interest in activities she previously enjoyed. PHQ-9 administered in session, score 16 (down from 19 at intake). Denied current suicidal ideation, plan, or intent when asked directly; reported passive thoughts that "things would be easier if I weren't here" twice in the past week, without intent. Discussed behavioral activation; client completed two of five planned activities from last session. Affect constricted, congruent with reported mood. Speech normal rate and volume.

Assessment: Major depressive disorder, recurrent, moderate (DSM-5-TR). Symptoms improving modestly, supported by a 3-point PHQ-9 decrease and partial completion of behavioral-activation tasks. Passive ideation present without active risk; safety reassessed and judged low-acute. Engagement is adequate. Primary barrier remains low activation energy rather than insight.

Plan: Continue weekly individual therapy. Increase behavioral-activation targets to five activities, scaffolded smaller to improve completion. Re-administer PHQ-9 in two weeks. Reassess passive ideation at each session and reinforce the safety plan on file. Coordinate with prescriber re: current antidepressant response at the next joint check-in. Next session in one week.

Notice what the Assessment does that the Data doesn't. The PHQ-9 score sits in Data as a fact. The interpretation, "improving modestly," lives in Assessment with the evidence attached. That separation is what makes the note defensible.

DAP note example: anxiety

Illustrative sample. Not a real patient. A weekly session for generalized anxiety disorder.

Data: Client reported a "high anxiety week," rating worry as 7 out of 10 most days, with difficulty concentrating at work and two episodes of racing heart and shortness of breath he identified as panic. GAD-7 score 14, unchanged from last week. Reported sleep onset delayed by racing thoughts, averaging five to six hours nightly. Practiced diaphragmatic breathing in session; client was able to bring subjective distress from 6 to 3 over four minutes. Reviewed cognitive-restructuring worksheet; client completed three of seven daily entries. Affect anxious, fidgeting, good eye contact.

Assessment: Generalized anxiety disorder (DSM-5-TR). Symptom burden stable rather than improving, with a flat GAD-7 and continued sleep disruption. Client demonstrates capacity to down-regulate acute distress in session, which is a strength to build on, but is not yet generalizing the skill between sessions, reflected in low worksheet completion. The two panic episodes warrant monitoring but do not currently meet a separate panic-disorder threshold.

Plan: Continue weekly CBT. Shift focus from new content to between-session practice, since the skill exists but isn't transferring. Assign one daily breathing practice at a fixed time rather than as-needed. Continue cognitive-restructuring worksheet, reduced to three entries to match realistic adherence. Screen for panic-disorder criteria next session if episodes persist. Re-administer GAD-7 in two weeks. Next session in one week.

DAP note example: PTSD

Illustrative sample. Not a real patient. A trauma-focused session for posttraumatic stress disorder. Note the heightened attention to risk and to what is, and is not, recorded.

Data: Client attended, guarded initially, settling over the session. Reported increased nightmares (four this week, up from two) and one flashback triggered by a car backfiring, lasting "a few minutes." Described avoidance of driving past the location of the index event. PCL-5 score 48. Reported hypervigilance and startle response as "worse than last month." Denied suicidal or homicidal ideation when asked directly. Engaged in a grounding exercise during a moment of elevated distress mid-session and recovered to baseline. Did not pursue trauma-narrative work this session by mutual agreement, given symptom elevation.

Assessment: Posttraumatic stress disorder (DSM-5-TR), with an increase in re-experiencing and arousal symptoms over the past month, supported by a rising PCL-5 and client report. Avoidance cluster active and currently reinforcing. Risk assessed and judged low-acute today, though symptom escalation warrants close monitoring. Client's ability to use grounding mid-session is a meaningful regulatory strength. Pacing trauma-processing work down is clinically appropriate given current arousal levels.

Plan: Hold trauma-narrative exposure until arousal stabilizes; prioritize stabilization and grounding skills next session. Add a sleep-hygiene and nightmare-management component. Reassess PCL-5 in two weeks. Reassess risk at every session while symptoms are elevated. Consider prescriber consult re: symptom escalation if no improvement in three weeks. Next session in one week.

For practices doing this work, two operational realities sit on top of the clinical note: how privacy rules apply, and what happens to any recording of the session. We cover both in the behavioral-health privacy guide, and the deeper psychiatry case in the psychiatry privacy post. In trauma work the recording is more sensitive than the note, so the audio question is the one to settle first.

DAP note example: substance use disorder (SUD)

Illustrative sample. Not a real patient. An individual session for alcohol use disorder, client in early recovery.

Data: Client reported 11 days of continuous sobriety, attending two mutual-support meetings this week. Described one significant craving on day 8, triggered by a social event, which he managed by leaving early and calling his sponsor. Reported improved sleep and appetite. Denied withdrawal symptoms. Discussed high-risk situations for the coming week, including a family gathering. Completed a relapse-prevention worksheet identifying three coping strategies. Affect brighter than prior sessions, engaged, future-oriented.

Assessment: Alcohol use disorder, moderate, in early remission (DSM-5-TR). Eleven days of sobriety with active use of recovery supports is clear early progress. The craving on day 8 was managed adaptively, which demonstrates emerging coping capacity. The upcoming family gathering is a foreseeable high-risk situation; planning for it is the priority. No current indication of withdrawal risk requiring medical escalation.

Plan: Continue weekly individual therapy alongside mutual-support attendance. Develop a specific written plan for the family gathering, including an exit strategy and a support contact. Reinforce the three coping strategies the client identified. Continue monitoring craving frequency and intensity. Reassess remission status against DSM-5-TR criteria monthly. Next session in one week.

A note on SUD documentation specifically: if your practice is a federally-assisted substance use disorder program, a separate confidentiality rule, 42 CFR Part 2, layers on top of HIPAA and changes how these records can be disclosed. The note structure doesn't change, but the handling does. The behavioral-health privacy guide walks through who that rule actually covers, because it's narrower than most assume.

What separates a strong DAP note from a weak one?

Four things. They apply the same way when you write the note by hand or when you review one a tool drafted.

First, the Data and Assessment stay separate. The most common documentation slip is smuggling judgment into Data ("client was manipulative") or restating raw facts in Assessment with no interpretation added. Keep the line clean: facts down here, reasoning up there.

Second, the Assessment names a diagnosis and justifies it. For a covered behavioral-health visit, the working diagnosis against the DSM-5-TR, the standard diagnostic reference published by the American Psychiatric Association, plus the reasoning, is what supports medical necessity. A note that describes a session beautifully but never lands a clinical judgment is incomplete.

Third, the Plan is specific and time-bound. "Continue therapy" is not a plan. "Weekly CBT, shift to between-session practice, re-administer GAD-7 in two weeks" is. Each item should be something a covering clinician could act on without calling you.

Fourth, risk is addressed when it's relevant. In depression, PTSD, and SUD work especially, the note should show that risk was assessed and what you concluded, not leave it to inference.

Why does the format matter when documentation is already eating your evenings?

Because the structure is the part you can standardize, and standardizing it is what makes the note faster to write and faster to defend.

The documentation load in behavioral health is well documented. A 2023 survey run by Harris Poll for the National Council for Mental Wellbeing, across 750 behavioral health workers, found that 93% had experienced burnout and 62% rated it moderate or severe. A third of the workforce said they spend most of their time on administrative tasks, and 68% of those providing direct care said that admin time takes away from time with clients. A 50-minute session followed by ten minutes of notes, repeated across a full day, is how a caseload turns into evening charting.

A consistent DAP structure helps two ways. It speeds the writing, because you're filling known sections instead of staring at a blank page. And it's where an AI scribe can take the first pass, drafting the Data section from the conversation and proposing an Assessment and Plan you then correct, rather than typing from scratch. The format is what makes that hand-off clean: a tool that knows it's writing into Data, Assessment, and Plan produces something you can review section by section.

AI Scribe by Patient Square is an ambient AI medical scribe that listens during the visit and hands back a structured SOAP note, ICD-10 suggestions, and a prescription draft — ready to review and sign about two minutes after the visit. The note itself is still yours to read, correct, and sign; the diagnosis and the clinical reasoning are your call, not the model's. What it removes is the blank page.

Use these examples, then grade a real note

The fastest way to judge whether a format or a tool works for you is to run it on your own caseload, not a sample.

Copy the example above that matches your next session as a starting template, write the note, and check it against the four marks: Data and Assessment separated, a named diagnosis with reasoning, a specific time-bound Plan, and risk addressed where it's relevant. If you're evaluating an AI scribe to take the first pass, book a demo to watch a structured note appear about two minutes after a sample visit, then run the 7-day free trial and grade three real notes the same way. For the full grading rubric that turns this into a buyer's scorecard, see our how to evaluate an AI medical scribe guide, and the SOAP note quality post if your setting uses the four-section format instead.

One more time, because it's the rule that keeps this page useful and safe: every DAP note above is an illustrative, clinician-style sample. None describes a real person. Write yours from the visit in front of you.