How to dictate DAP, SOAP and BIRP notes (with example scripts)

All three are ways to organize the same progress note. They differ in how they split up what happened in the session. Your agency, payer or supervisor may require one of them; if nobody does, pick the one that matches how you think about sessions and stick to it.

DAP folds what the client said and what you observed into one Data section. SOAP keeps them apart: Subjective is the client's report, Objective is what you observed or measured. BIRP puts your intervention in its own section, which makes it easy for a reviewer to see what you did and how the client responded.

The method that holds up best is short and boring: dictate one section at a time, right after the session, while you still remember it.

1. Open the note template in your EHR before the next client arrives.
2. Click into the first section's text field.
3. Hold your dictation key and say two to four plain sentences. Release.
4. Glance at the text, fix anything misheard, then click into the next section.
5. Read the whole note once before you sign it.

Short bursts work better than one long monologue. If you say the whole note in one go, you end up hunting through a wall of text to move sentences into the right fields. With push-to-talk dictation such as Sapience Med, the text lands in whichever field your cursor is in, so each section goes where it belongs as you speak. If your EHR gives you one big text box, type the section headings once (or keep them in your template) and dictate under each one.

This is what you would actually say, section by section. The client and details are invented.

DATA
Client attended a 53-minute individual session via telehealth. Client reported that sleep improved to about six hours a night since starting the wind-down routine. Client described two panic episodes this week, both before work meetings. Client completed the GAD-7 today with a score of 12, down from 15 two weeks ago.

ASSESSMENT
Anxiety symptoms are trending down and the client is using the breathing skills between sessions. Panic remains tied to work performance situations. Client denied suicidal or homicidal ideation.

PLAN
Continue weekly CBT. Next session, build an exposure hierarchy for meeting-related anxiety. Client will log panic episodes and the skill used in each. Next appointment Tuesday at 10 a.m.

Notice that the dictation is plain speech. You do not need special phrasing; say it the way you would write it.

SOAP is common for psychiatric follow-ups, where drug names and doses matter. This is where a general dictation tool tends to stumble, because names like lamotrigine or Vraylar are rare in everyday speech.

SUBJECTIVE
Patient reports mood is "steadier" since the last visit. Sleeping seven hours. Denies rash. Reports mild morning nausea in the first week that has resolved. Taking lamotrigine 100 milligrams daily as prescribed.

OBJECTIVE
Alert and oriented times three. Speech normal rate and volume. Mood "okay," affect euthymic. Thought process linear. No SI or HI. PHQ-9 score 8, previously 14.

ASSESSMENT
Bipolar II disorder, current episode depressed, improving on lamotrigine. Tolerating titration well.

PLAN
Increase lamotrigine to 150 milligrams daily. Reviewed rash warning signs again. Follow up in four weeks or sooner if needed.

Say doses the way you would read them aloud ("one hundred milligrams"). Check numbers and drug names every time before you sign; that is the one review step you should never skip, whatever tool you use.

BEHAVIOR
Client arrived on time and appeared tired. Client reported an argument with a roommate over the weekend and said they "shut down" afterward. Client was tearful when describing the conflict.

INTERVENTION
Clinician used DBT chain analysis to map the events before and after the argument. Clinician reviewed the DEAR MAN skill and role-played a conversation with the roommate.

RESPONSE
Client identified the point where they stopped talking and linked it to fear of rejection. Client practiced DEAR MAN twice and said the second attempt felt "doable."

PLAN
Client will use DEAR MAN with the roommate this week and note the outcome on the diary card. Continue weekly DBT individual sessions.

BIRP is the most explicit of the three about cause and effect. When you dictate the Intervention section, name the technique you used. "Discussed coping skills" tells a reviewer very little; "reviewed DEAR MAN and role-played it" tells them what happened.

A progress note is part of the client's medical record. HIPAA treats it differently from psychotherapy notes, which are a clinician's separate process notes about the content of a session. Under 45 CFR 164.501, psychotherapy notes specifically exclude medication prescription and monitoring, session start and stop times, the modalities and frequencies of treatment, results of clinical tests, and any summary of diagnosis, functional status, the treatment plan, symptoms, prognosis and progress to date.

That list is a useful checklist for what belongsin the progress note. Detailed session content, your private hypotheses and long verbatim quotes usually do not. Keep quotes short and use them only when they show something clinically important, such as the client's own words about safety.

Speak in finished sentences and pause where a period would go; punctuation comes out cleaner that way. Leave client names out of the body, since the EHR already ties the note to the client, and "client" or "patient" reads fine. If you use unusual drug names, local program names or your own abbreviations, add them to the custom vocabulary once so they come out right every time after that.

And don't save notes for later. A note dictated five minutes after the session is mostly recall. At 9 p.m. it is guesswork.

If you want to see how this fits a whole day, our guide on writing therapy notes faster without recording sessions covers scheduling and templates. For EHR specifics, see dictation for SimplePractice and dictation for TherapyNotes.