Clinical notes are essential to well-managed client care, whether your health clinic delivers physical therapy, speech therapy, skin care, mental health, or any other service. They’re the single source of truth that documents symptoms and treatment throughout your client’s care journey.
And yet, clinical notes can also be a burden to practitioners. Getting bogged down in admin takes away valuable time from client interaction and care, making an already demanding job more challenging. Streamlining the process of taking clinical notes is critical to running an efficient, effective practice.
We put together this guide to provide practitioners with essential resources and templates for streamlining their practice’s note-taking process. It includes templates, tips, important definitions, and resources to help you create a system that works for your business. Each section below provides a brief overview of the topic and links to deeper explorations on each subject.
Clinical Notes Vs. Progress Notes
In healthcare, the terms “clinical notes” and “progress notes” are sometimes used interchangeably. However, there is a key difference between the two. While clinical notes can include any type of notes recorded on a client’s health record, such as intake information, test results, and long-term treatment planning, the term “progress notes” refers specifically to the notes taken during appointments. This includes any changes to the client’s condition, treatments and outcomes.
Both clinical notes and progress notes are critical for providing quality client care, but progress notes refer to a more narrowly focused subset of clinical notes which track a client’s ongoing progress.
How to Write Clinical Notes
Writing useful and effective clinical notes is an art form. Notes must be clear and succinct but also contain key details central to a client’s treatment plan. Client concerns must be clearly documented and addressed respectfully. In fact, clients should be able to read their own notes and understand what was discussed during their appointments if needed.
There may also be times when courts request your clinical notes for legal proceedings. This is another reason why ensuring that your notes are clear, unbiased, and accurately reflect your management plans is essential.
With all this in mind, how can practitioners develop an effective process for clinical notes? Let’s dive into a few key components to help you create the best clinical note-taking system for your practice.
How to Write Clinical Notes Faster
There isn’t a magic bullet for writing notes faster, but there are effective methods that can help you increase efficiency without sacrificing quality.
In brief, you should do the following:
- Use templates as much as possible (see further below for some examples of handy templates).
- Audit your templates regularly – It’s very important to have a series of templates addressing the most common client needs in your practice. You should configure them as much as possible to speed up efficiency and review them regularly to ensure they continue to meet your needs.
- Use an internal EMR / EHR system that makes clinical notes as simple as possible. There are more resources below on clinical notes software.
Want to read more about efficient clinical notes? Check out our more detailed guide on how to write clinical notes faster.
What Software Helps With Clinical Notes?
There are numerous software solutions designed to help providers with notes. You can choose between stand-alone solutions designed exclusively for clinical notes or go further with a full EMR / EHR system that also includes features for client scheduling, billing and more.
If you’re looking for a more comprehensive solution that includes booking, scheduling, billing and more, it makes sense to consider a practice management software for clinical notes like ours. Power Diary helps practitioners save time and provide better care by streamlining all the crucial tasks of running a successful practice. There are other solutions available, so take the time to explore your options and find one that’s right for your practice.
What are DAP Notes, and How Are They Used?
The “DAP” in DAP Notes stands for Data, Assessment and Plan.
DAP notes are a tool used by mental health professionals around the world. From social workers to psychiatrists, DAP notes are used to record client progress and inform treatment plans.
In each DAP note, the provider details the “Data” (why the client is coming, client presentation and symptoms, any interventions applied and other relevant details.), “Assessment” (general progress of the client and any changes to diagnosis), and “Plan” (things like the date of the next session and any “homework” for the client).
For more information on this form of note template, check out our comprehensive DAP notes guide.
What are SOAP Notes, and How are they Different from DAP Notes?
SOAP notes are another way to document client progress and treatment in healthcare. What’s the difference between these two formats?
Both note formats require the note-taker to document subjective and objective data. The difference between the two comes down to how you record this information. DAP notes merge both subjective and objective data, whereas SOAP notes segment this information.
Let’s try and explain.
As previously mentioned, DAP stands for Data, Assessment and Plan.
The “D” for Data combines all data, whether objective or subjective.
SOAP stands for Subjective (Data), Objective (Data), Assessment and Plan.
The “S” and the “O” in SOAP notes are segmented versions of the “D” in DAP notes. Subjective data includes information such as the client’s experience and perception of symptoms and progress. Objective data includes observable data such as a mental status exam, medications prescribed or any historical information.
For more reading, check this comparison of SOAP notes vs DAP notes. It includes some practical tips and different perspectives on when you might consider one format over the other.
How to Write Progress Notes for Mental Health
Whether you’re writing DAP notes or SOAP notes, following a series of best practices for mental health notes is important.
Check out the following article on common mistakes to avoid when writing mental health progress notes.
If you’re looking for some specialty-specific examples for notes, please see our running list of resources below.
Progress Notes Examples
We’ll continue to update this section as we publish more resources.
SOAP Notes for Mental Health
If you’re using the SOAP format in your practice, this is our best resource for writing SOAP notes for mental health.
SOAP Notes for Speech Therapy
If you’re a speech pathologist looking for a head start with SOAP notes, check out our take on SOAP notes for speech therapy.
DAP Notes Examples
If you’re using the DAP format in your practice, check out these DAP note tips and a detailed example.
Clinical Notes Wrap-up
We hope you’ve found this clinical notes guide to be a helpful resource. For more, consider reviewing the comprehensive resources found at HealthIT.gov. The NIH also has a resource about all things SOAP notes here.
And if you’re involved with practice management for a small to midsize practice (single practitioner to multiple locations), consider our 14-day free trial to determine if Power Diary’s comprehensive software for clinical notes and practice management is right for you!