After watching the interview video below, please write the formal DAP note from the perspective of the case manager. Be sure that the information of the interview is in the proper category and the important aspects of the interview is addressed within the note.
What is it about?
A DAP: Data, Assessment, Plan (or SOAP: Subjective, Objective, Assessment, Plan) are the two industry standards of writing notes. It is important to break down the actions and observations of an interaction with a client versus an analysis and assessment. This helps prevent bias in the note writing and allows others who read the note to see exactly what happened and perhaps come up with their own assessment.
The Data piece is to be written about just the observed facts. This is the section where you write about the intention of your encounter and what is observed. You do not use assumptions in this section. So for example, if you suspect a client is nervous (an assumption based on observations) you would write the actions that they did to cause you to assume they were nervous. You might write that “client was sitting in the chair. She was twitching her left foot and both of her hands at a rapid rate and was looking all around the room. She did not make eye contact as we spoke.” This section is as if you were explaining action by action of what the person was doing.
The Assessment is where you can put your analysis. You can say that based on the actions and images you observed, the client appeared nervous, happy, high, depressed, etc.
The Plan is the next step. Even if it is your last encounter with the client, there needs to be explanation of what happens next . If you talked about directives with the client the plan might be for the client to follow through on the directives, and perhaps a detailed description of how they will do so, as well as what you, the case manager will be doing. Perhaps, you will call client in two days, or call another agency, make a referral, etc.
How this will help in the future?
In any helping profession, the adage goes, if it isn’t documented, it didn’t happen. It is necessary for good practice to document all encounters with clients. This needs to be done for appropriate case planning, as well as continuity of care (If you leave your job for vacation or permanently, the next case manager should be able to read your notes and know exactly where to pick up), and it also needs to be done for billing. While note writing can feel like an extra burden, it really is helpful in your own work load. If you are working with multiple clients, it can be easy to mix up cases and stories. If a client calls you and you have your file handy, you can easily look and know exactly who you are talking to and answer questions appropriately. Also, the act of watching other interviews helps you to assess what works, what doesn’t and how to read a client’s body language while not being engaged in the actual conversation.
Video: MSW Assessment Interview 1 – YouTube
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