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Guest Post: Tips for Writing Notes Part 3 – Putting It All Together with a Template

Blog 1Guest Post by Dr. Maelisa Hall. This is part 3 of a 3 part series on clinical documentation.

Now that we’ve covered the mindset needed for good clinical notes, let’s get to the technical part- templates. I recommend every therapist pick a template they like and stick to it (or try a new template if you hate the one you’re currently using). This saves you time because you get familiar with documenting in one format and you quickly get in a “groove” when writing. Here are four easy and popular templates that can work for any practice:

DAP

Data– Subjective and objective information from your session. This can include things such as client quotes, therapist directives, family interactions, and general feelings present in session.

Assessment– Your current assessment of the client’s progress. You can also include any diagnostic impressions or possible changes.

Plan– What you and/or your client plan to do between sessions or focus on next session.

GIRP

Goal– The client’s long-term goal and current focus of therapy. You may have more than one. These can be broad (reduce depression) or specific (increase daily communication with spouse) and may change throughout treatment.

Intervention– The actions of the therapist during the session. Did you challenge, support, reflect, assign homework, etc.

Response– The response of the client to the therapist’s actions. This is also where you add client quotes, client actions (yelled, cried, avoided), and client presentation (sad affect).

Plan– What you and/or your client plan to do between sessions or focus on next session.

PAIP

Problem– The “problem” you and the client have identified to work on in treatment. Like the Goal in GIRP, this may be broad (experiencing anxiety) or more specific (difficulty engaging in intimacy due to sexual trauma).

Assessment- Your current assessment of the client’s progress along with diagnostic impressions. For this format, you could add client quotes and responses here.

Intervention– The actions of the therapist during the session. Did you challenge, support, reflect, assign homework, etc.

Plan– What you and/or your client plan to do between sessions or focus on the next session.

SOAP

Subjective– The subjective, or inferred, information present in the session. This can include the therapist’s impression of the client and the client’s subjective views of progress and treatment (e.g. client reported feeling improvement but was unable to identify strengths in herself during the session).

Objective– The objective, or observable data present in the session. This is the information that any layperson could easily see and hear (client quotes and actions).

Assessment– Your current assessment of the client’s progress. You can also include any diagnostic impressions or possible changes.

Plan– What you and/or your client plan to do between sessions or focus on the next session.

You’ll notice these are all similar but have different nuances that may work better for different professionals and client populations. For example, if you do more short-term or directive work you may like the GIRP format since that easily keeps you on track for specific goals. If you tend to do more long-term work and focus on broad issues and general life improvement you may prefer DAP since it is direct but open-ended.

I’m sure you want to see what each of these formats look like when used with a real client. Click here to see a sample note for each template using a mock case example for Leah, a 32-year-old woman in treatment for anxiety and depressive symptoms related to a custody dispute with her former husband.

The general theme is that you want to include information that shows you are continually assessing your client, have at least a general focus for treatment and plan to follow-up with your clients (even if that just means seeing them next week at their usual time). By documenting this you are showing that you’re following the standard of care by following a treatment plan that is appropriate for your client’s needs and meeting your professional standards.

Headshot - Dr Maelissa Hall_resizedMaelisa Hall, PsyD is a clinical psychologist who teaches therapists how to create rock-solid documentation so they can spend more time with their clients and less time worrying about paperwork. Find out more about Maelisa and her work by clicking here!

 

 

 

 

 


 

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Guest Post: Tips for Writing Notes Part 3 – Putting It All Together with a Template

 


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APA Reference
Higdon, K. (2019). Guest Post: Tips for Writing Notes Part 3 – Putting It All Together with a Template. Psych Central. Retrieved on August 22, 2019, from https://pro.psychcentral.com/kickstart/2014/10/guest-post-tips-for-writing-notes-part-3-putting-it-all-together-with-a-template/