Writing DAP notes a client could read

Clients have a right to request most of their records, and more of them now read their records online. In a 2024 federal survey, 65% of people had been offered online access to their medical records or a patient portal and had used it, up from 25% in 2014. A progress note written as if the client will read it tends to be a better note anyway. It is specific. It sticks to what was said and observed, and it leaves out labels that say more about the writer's mood than about the client.

Here is how I write each section of a DAP note with that reader in mind, and where my own analysis goes instead.

What clients can ask to see

With limited exceptions, the HIPAA Privacy Rule lets people see, on request, the health information their providers keep about them in designated record sets. HHS lists medical and billing records among those, along with clinical notes such as SOAP notes. A DAP progress note is a clinical note like any other.

The main exception for therapists is psychotherapy notes kept separately from the medical record. Clients have no HIPAA right to access those, though you can choose to share them.

The reader may also be someone other than the client. In the same survey, the share of people who used the portal of someone they care for rose from 24% in 2020 to 51% in 2024. Among portal users whose provider encouraged them to use it, 82% had viewed clinical notes in the past year.

Data, assessment, plan

In the data section, quote or paraphrase what the client said, and describe what you observed. "Client used the breathing exercise on 4 nights and fell asleep faster on 3" tells the care team what happened, and the client will recognize it. "Client was resistant" mostly records how the session felt to you. If something happened that you'd call resistance, write the behavior: the client said they didn't want to talk about their sister today and changed the subject twice.

In the assessment, connect what you recorded to the treatment goals and to any measures, such as a GAD-7 score. "Generalized anxiety disorder, improving. GAD-7 10, down from 14 last month" shows progress in terms both the client and the next clinician can follow.

In the plan, write the next step in words the client would recognize from the session. If you agreed on 15 minutes of worry time after dinner, the plan should say that in the same words. Charted drafts DAP notes in this order and carries homework from the session into the plan.

What belongs in a psychotherapy note

HHS defines psychotherapy notes as notes a mental health professional records to document or analyze the contents of a counseling session, kept separate from the rest of the medical record. The definition leaves a lot out. It excludes medication prescription and monitoring, session start and stop times, the modalities and frequencies of treatment, and results of clinical tests. It also excludes summaries of diagnosis, functional status, treatment plan, symptoms, prognosis and progress to date.

So the GAD-7 score stays in the progress note, along with the diagnosis and the plan. What can move is your own analysis: a hypothesis you're testing, or a pattern across sessions that you aren't ready to put in the chart.

How Charted keeps them apart

Since version 3.5, released September 3, you can mark your own analysis from a session as a psychotherapy note. It stays in Charted, separate from the progress note, and never goes to the shared chart. The marked passage is also removed from the transcript linked to the progress note, so it exists only in the psychotherapy note. That separation is what keeps the protection in place. Paste the same analysis into the progress note and it becomes part of the record the client can request.

Before you sign, read the draft for tone as well as accuracy. I read each line as if the client were reading it back to me at our next session.

Questions we get

Should a GAD-7 score go in the psychotherapy note?

No. The HIPAA definition excludes results of clinical tests and summaries of symptoms and progress, so the score belongs in the progress note with the assessment.

Can I share a psychotherapy note with another provider?

Generally only with the client's authorization, even when that provider is treating the same client. HHS notes an exception for disclosures required by other law, such as mandatory reporting of abuse or a mandatory duty to warn.