Whether you need a SOAP note, a DAP note, or some other type of progress note, you're still including the same sorts of details... just organized a bit differently. Quill is looking for these details too when you submit your session summary. (And then using AI, it organizes them appropriately into a proper note.)
Here's a breakdown of the details to include in your summary:
- Session duration and location (e.g., virtual/telehealth or office)
- Reason for visit and chief complaint/presenting problem
- Client presentation, appearance, and mental status
- Direct quotes from the client
- Reported symptoms or important events since the last session
- Topics mentioned by the client during the session
- Screening results and applied interventions
- Client's response to interventions and progress since the last encounter
- Progress in relation to treatment goals and any diagnosis changes
- Changes to the treatment plan and future steps
- Assigned homework and provided referrals
- Planned third-party contact or consultations
- Details of the next session (date, time, location)
For convenience, we now show you this list when you generate a new note. (Just click "Generate Note".) Think of it as a little script to help remind yourself of what to include and say as you record (or type) your summary.
But remember! Not all of these details are required. This is merely a guide or list of recommendations.