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Treatment plans and progress notes, on one page
What CRPO's record standard asks of a therapy plan and progress notes, how to turn a goal into a measurable objective, and the same session written as a SOAP and as a DAP note.
Study aid, not legal advice.Last verified against the official sources linked below on .
What CRPO's standard asks
- A plan for therapy that reflects your modality: at least the direction therapy will take, the client's first and later consents, and each change to the plan.
- Progress notes: the client's statements, your observations, your impressions, and the plans you propose in response.
- Every entry shows who wrote it and when; kept up to date, legible, in plain language; key information in English or French.
- Amendments show what changed, when, by whom and why, with the original still legible.
- CRPO asks for this content, not a format: SOAP and DAP are two common ways to hold it.
From goal to measurable objective
| Part of the plan | Example, built with the client |
|---|---|
| Goal, in the client's words | "Feel less anxious at work and get back to team meetings." |
| Objective: observable, measured, dated | Attend at least three of four weekly team meetings by week 8, rating anxiety 5 out of 10 or lower during them. |
| Interventions | Graded exposure to meetings, paced breathing, a meeting log reviewed each session. |
| Measure and review | GAD-7 at intake, week 4 and week 8 (Spitzer et al., 2006, Arch Intern Med 166(10):1092-1097); review the plan together at week 8. |
| Consent | Approach, options, risks and benefits discussed and the client's agreement recorded with the date (3.2.6). |
One session as a SOAP note
| Part | Example (a fictional client) |
|---|---|
| Subjective | Says the week was "better than last": went to two of four team meetings, skipped Friday's after a poor night's sleep. |
| Objective | On time; steady speech; tearful once describing Friday. GAD-7 12 (14 at intake). Meeting log complete. |
| Assessment | Partial progress on objective 1 (2 of 4). Avoidance rises after poor sleep. Asked about thoughts of self-harm: none. |
| Plan | Next exposure step: speak once in a meeting. Add a sleep routine. Review the log next session. |
The same session as a DAP note
| Part | Example |
|---|---|
| Data | Went to two of four team meetings; skipped Friday's after poor sleep ("better than last week"). On time, steady speech, tearful once. GAD-7 12 (14 at intake). |
| Assessment | Partial progress on objective 1. Avoidance linked to sleep. No thoughts of self-harm when asked. |
| Plan | Speak once in a meeting; add a sleep routine; review the log next session. |
Notes that hold up
- Same day, while it is fresh; rough notes not kept are destroyed once the record is written, the same day.
- Facts apart from impressions, and the client's own words where they matter.
- Record risk, consent, consultations, referrals and any report made.
- Write as if the client will read it: they generally may (PHIPA).
- Notes on your own process for supervision, without identifying the client, are not part of the record.
Plan with the client, measure what you agreed, and let each note show what was said, seen, thought and planned.