![]() It is beneficial to discuss affect, attitude and cognition in behavioral terms and use the phrase “as evidenced by” to specifically describe patient behavior. Documentation should always be concise and specific. It is also important to document any discharge recommendations and plan for transition of care.Īdditions items to document are as follows:Ĭharting should be timely and completed by the end of shift. The clinician must have clear goals and objectives that the patient is aware of so that patient progress can be effectively measured. It is also important to describe the patient’s response to interventions that have been utilized. ![]() When you use DAP note examples in healthcare institutions, you would follow the standard format that includes data, assessment, response, and a plan for the medical care of your patients. The purpose of documentation is to continually assess our patients affect, attitude, cognition and behavior. 28 Free DAP Notes Examples & Templates When used in medical settings, the DAP in DAP notes stands for Diagnostic Assessment Program. Proper documentation is essential for continuity of care in mental health. The details are important when you are making a psychiatric progress note. Their complete name, address, contact details and of course the assessment you have made about them. Just as you will notice with any kind of progress note, you will need the correct details about your patient. Much of my experience comes from inpatient mental health. Add the Correct Details about the Patient. ![]()
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