---
title: "How do I write DAP notes with an AI scribe? — Hanah"
description: "What goes in each section of a DAP note, a worked example, how an AI scribe drafts it from a session, what you still need to check, and the report back to the GP under Better Access."
source: https://hanah.health/blog/how-to-write-dap-notes-with-an-ai-scribe/
---

[← All posts](https://hanah.health/blog/) Article [Psychologists](https://hanah.health/blog/psychologists/)

# How do I write DAP notes with an AI scribe?

The Hanah team · 12 September 2026

A DAP note has three sections: Data (what the client reported and what you observed), Assessment (what you make of it) and Plan (what happens next). An AI scribe can draft all three from a recorded session. It can't decide what belongs in the record, and it can't know what you think. Those parts stay with you.

Below is the format, a worked example, how [Hanah for psychologists](https://hanah.health/psychologists/) drafts each section, what to check before you sign, and the report back to the referring GP. If you're still choosing a scribe, start with [what to look for in an AI scribe for psychologists](https://hanah.health/blog/ai-scribe-for-psychologists/).

## What goes in each section of a DAP note?

**Data** is the factual record of the session: what the client reported, what you observed (presentation, affect, engagement), any measures you administered, and what you covered. It describes. It doesn't interpret.

**Assessment** is your clinical interpretation: how today's presentation fits your working formulation, whether the client is progressing, and anything that changes your view of risk.

**Plan** is what happens next: the focus of the next session, between-session tasks, any liaison or referral, and when you'll review.

The discipline of the format is keeping Data and Assessment apart. "Client was avoidant" is an interpretation. "Client changed the subject twice when the supermarket came up" is data.

## How is DAP different from SOAP and BIRP?

SOAP (Subjective, Objective, Assessment, Plan) separates what the client reports from what you measure. That suits a physiotherapist recording range of motion. In therapy, most "objective" material is your observation of the conversation, so the split can feel forced. DAP folds both into Data.

BIRP (Behaviour, Intervention, Response, Plan) centres the note on what you did in session and how the client responded. It's useful when you need to show the intervention delivered.

No format is more correct. Use the one your practice, supervisor or funder expects.

## What does a good DAP note look like?

_Illustrative example, written by hand to show the format. The client is fictional._

Sam, 34, is at session 4 of an initial course of six under a Better Access referral, working on panic with CBT.

> **Data**
> 
> Sam reported two panic episodes on the train this week, down from four the week before, peaking at 7/10. Completed thought records on three days. Stayed away from the supermarket on Saturday "in case it happened there". DASS-21 re-administered: anxiety 14 (18 at intake). Arrived on time; good eye contact; speech faster when describing the train, settled when discussing work. Asked directly about thoughts of self-harm or suicide; Sam denied any, consistent with previous sessions.
> 
> **Assessment**
> 
> Reduced panic frequency is consistent with the working formulation (catastrophic misreading of bodily sensations, maintained by avoidance). Thought records show Sam beginning to test the "I'll faint" prediction. Supermarket avoidance remains the main maintaining factor. No change in risk; protective factors (partner, stable work, engagement in therapy) unchanged.
> 
> **Plan**
> 
> -   Next session: begin interoceptive exposure in session.
> -   Between sessions: thought record after each episode; two 10-minute supermarket visits at a quiet time.
> -   Session 6: re-administer DASS-21 and send a written report to the referring GP.

## How does an AI scribe draft each section?

In Hanah, a psychologist's starter library has a DAP intake assessment (written in full prose), a DAP progress note (in the Standard register) and a referral letter. Each template is a set of headings with fill-in slots, and each slot carries an instruction. The DAP template asks for:

-   **Data:** what was observed and reported in session (presentation, symptoms and engagement), factual and neutral, in one short paragraph.
-   **Assessment:** the clinical impression and progress, in a sentence or two relating today's presentation to the working formulation.
-   **Plan:** short points covering ongoing treatment, between-session tasks and review.

The draft is written from the session transcript, plus anything you typed into the visit's Context notes. A few rules shape it:

-   The model is told to use only this session for clinical facts, and not to infer or invent.
-   If something wasn't discussed, its slot is left out rather than padded with filler.
-   Client statements are paraphrased by default. Turn on "Use quotes" if you want direct quotes where they matter clinically.
-   For a progress note, the last note from the same template for the same client is shown as a guide to structure and wording, not as a source of facts. Every fact has to come from today.
-   You choose the register: Shorthand, Standard or Full prose.

If your notes live in Cliniko, Hanah drafts into your Cliniko treatment-note template, keeps its headings exactly, and leaves a question blank when nothing in the session answers it. The browser extension also works inside Halaxy, Nookal and Zanda.

These are instructions to a model, not guarantees. We publish our measured error rates in our [accuracy and hallucination report](https://hanah.health/transparency/), and the checks below are still yours to make.

## What do you still need to check?

[Ahpra's guidance on AI in healthcare](https://www.ahpra.gov.au/Resources/Artificial-Intelligence-in-healthcare.aspx) is direct about this: if you use an AI scribe, you're responsible for checking the accuracy and relevance of the records it creates. Hanah drafts, and nothing goes into the record until you've reviewed it. In psychology, four things deserve a close read.

**The Assessment is yours.** It's the section where a draft does the most interpretive work, so read it hardest. It should say what you think, not what a model inferred. If you haven't voiced your formulation in the session, type a line into the visit's Context notes before you draft.

**Neutral language.** The Psychology Board of Australia's [Code of conduct](https://www.psychologyboard.gov.au/Standards-and-Guidelines/Professional-practice-standards/Code-of-conduct.aspx), in effect since 1 December 2025, asks for records that are factual and objective and that contain no demeaning or derogatory remarks. Clients also generally have a right to access their records. Swap labels for behaviour: "resistant" becomes "declined the exposure task, saying it felt too soon".

**Risk.** A scribe can only document what was said. If you asked about suicidal thoughts and the client answered, that exchange is in the transcript and can be drafted. If you judged risk from something unspoken, it isn't, and you need to add it. The starter DAP template has no dedicated risk slot, so if your practice records risk every session, add one. When risk wasn't discussed, the slot is left out, and that gap is your cue to write the line yourself.

**What not to record.** The scribe hears everything: the story about the client's sister, the name of the colleague they're in dispute with, the full detail of a trauma narrative. The Code asks you to collect only the personal information that's reasonably necessary for the service. Hanah can't know what's clinically unnecessary for this client, so cut it before you sign.

Consent comes before all of this. Ahpra expects informed consent before you use an AI scribe, ideally noted in the record. The [APS practice guidelines on AI](https://psychology.org.au/insights/use-ai-in-practice-new-aps-practice-guidelines) go further and ask for written consent that is specific to the tool.

## How do you write the letter back to the GP under a Mental Health Treatment Plan?

Under Better Access, Medicare rebates are available for up to 10 individual sessions a calendar year, and the initial referral covers a course of up to six. At the end of that initial course you must send the referring practitioner a written report on the assessments carried out, the treatment provided, and your recommendations for future management, including whether a further course is needed. Another report is due at the end of any later course. Since 1 November 2025, GP referrals have to come from the client's MyMedicare-registered practice or their usual medical practitioner. The rules change, so check the current [Better Access fact sheet for health professionals](https://www.health.gov.au/sites/default/files/2026-03/better-access-fact-sheet-professionals_0.pdf) rather than relying on this summary.

The report covers a course, not a session. In Hanah's **Draft a document** dialog you pick the client and the past sessions to draw from, and it drafts one document from all of them.

The starter referral letter is written in full prose, and the client's name, today's date, your name and the practice name are filled in from your records and copied through unchanged. The GP's name is drafted from what was said in the session, so check it.

That starter letter is general-purpose, with a paragraph for examination findings. For Better Access reports, edit it so each required element has its own slot. In the template editor a slot shows highlighted, with its instruction attached. Written out:

```
[assessments carried out](measures used this course, with scores at the start and end where given)
[treatment provided](the approach taken and what the sessions covered)
[recommendations for future management](whether a further course is recommended, and why)
```

Check the session count, dates and scores against your records before it goes.

## Frequently asked questions

**Can I keep using SOAP, BIRP or my practice's own format?** Yes. Give Hanah your headings and it fills them. It can also [fill your existing Word and PDF templates](https://hanah.health/blog/byo-template-docgen/).

**Will the note include things the client said in passing?** It can, if the model judges them relevant. Read the Data section with that in mind, and remove anything that isn't clinically necessary before you sign.

**Where is the session data kept?** In your region: Australian practices are hosted in Australia, New Zealand and UK practices in theirs. The Trust Centre for [Australia](https://hanah.health/au/trust/), [New Zealand](https://hanah.health/nz/trust/) or the [UK](https://hanah.health/uk/trust/) lists every control and subprocessor.

To see how Hanah drafts DAP notes and GP reports in your own practice, [see Hanah for psychologists](https://hanah.health/psychologists/) or book a demo below.

[Hanah for psychologists →](https://hanah.health/psychologists/)

See Hanah in your own practice.

[Book a demo](https://hanah.health/index.html#demo)