Substance use DAP note example: preserve source and time frame

Begin with the exact information available

A statement about use needs a source and a relevant time frame. Client reports no use since a stated date is different from a verified test result or an author’s broader assessment. Do not change one into another for brevity. SAMHSA’s TIP 42 provides professional context for assessment of co-occurring conditions. It is not a license for a drafting tool to infer missing history, clinical status, or treatment needs from a short source paragraph.

Fictional source for a limited note

Fictional client reports attending one scheduled support meeting during the past week and describes difficulty arranging transportation to another. Therapist reviews the client’s own account of the scheduling obstacle and facilitates a list of questions the client wants to ask the meeting organizer. Client writes down two questions and agrees to contact the organizer. The therapist supplies an assessment that the attendance report and practical obstacle warrant follow-up. The source supplies no current use history, test results, diagnosis, or risk findings.

An original DAP draft

D: Client reports attending one support meeting in the past week and difficulty arranging transportation to another. Therapist reviewed the reported obstacle and facilitated a question list. Client wrote two questions for the organizer.

A: Author-supplied assessment: the reported attendance and transportation obstacle warrant follow-up. Other clinical findings were not supplied in this fictional source.

P: Client agreed to contact the meeting organizer about the two questions before the next scheduled session.

Attendance is not treated as evidence of abstinence, clinical stability, or treatment success.

Check familiar but unsupported conclusions

Words such as sober, stable, compliant, and relapsed can carry clinical or temporal implications that exceed the source. Replace an unsupported shortcut with the supplied report or observation, then let the professional decide what interpretation is justified. If a test result is actually supplied, preserve its date and source rather than implying continuous knowledge of behavior between tests. Avoid inserting routine symptom denials or medication statements from a previous sample. The absence of a supplied finding cannot resolve a clinical question.

Keep sensitive-record decisions outside this pilot

This public editor is for fictional or de-identified practice material. It does not manage specialized confidentiality requirements, permissions, assessments, or disclosure workflows. Those decisions belong to the responsible organization and professional. For the drafting exercise, select DAP and verify that each sentence remains traceable to its source field. A missing information marker can help reveal an incomplete summary, but it is not a substitute for assessment or the documentation actions that may be needed in an actual encounter.