DAP Notes for Schizophrenia: Template + Examples (2026)
Overview
This guide is part of our complete DAP notes hub — format structure, a full clinical example, the DAP note generator, and all 72 diagnosis-specific templates.
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Short answer: a DAP note for schizophrenia has three parts. Data: what the client reported (voices, beliefs, sleep, function, substance use, medication as they describe it), what you observed on the mental status exam, any scores and the interventions you used, such as cognitive behavioral therapy for psychosis (CBTp). Assessment: your interpretation: symptom severity and change, insight, function, early warning signs of relapse and risk. Plan: next steps, coping practice, coordination with the prescriber or treatment team, family involvement and repeat measures.
Describe psychotic symptoms in the client’s terms and in specifics (“hears a male voice saying ‘you’re useless’ several times a day, distress 6/10”), not only “AH present.” Record command hallucinations and any beliefs that involve harming self or others every time, and note who prescribes and manages medication; therapy notes record reported adherence and side effects, not dose decisions.
What to document in a DAP note for schizophrenia
| Section | What to document | Example wording |
|---|---|---|
| Data | Voices and beliefs in specifics, function, sleep, substances, reported adherence, mental status, scores and the interventions used | “Hears a critical male voice several times a day. PSYRATS-AH 22 (30 at intake). Practiced a coping card for the voice.” |
| Assessment | Severity and change, insight, function, early warning signs and risk | “Voices less distressing; insight partial; no early warning signs this week; acute risk low.” |
| Plan | Coping practice, coordination with the prescriber, family involvement and repeat measures | “Use coping card daily; share relapse plan with mother; update psychiatrist with consent; PSYRATS in 4 weeks.” |
Safety. People with schizophrenia have a much higher suicide risk than the general population, particularly early in the illness and after a hospital discharge. Ask directly and record the answer. If a client reports suicidal thoughts, assess and record current thoughts, plan, intent, preparatory behavior, past attempts, access to means (including firearms and medications), protective factors, your risk formulation and the safety plan. Ask about command hallucinations and any beliefs about harming others, and record their content and whether the client intends to act on them. Commands or intent to harm self or others need a same-day risk assessment and an emergency response if danger is imminent. The 988 Suicide & Crisis Lifeline takes calls and texts at 988; for imminent danger, call 911 or go to the nearest emergency department.
How to Document DAP Notes for Schizophrenia & Psychotic Disorders
Data
Combine subjective reports and objective observations into a single data section
In Data, record the client’s reports (symptoms, triggers, function, medication adherence as reported), your observations and mental status findings, measure scores, the interventions you used and the client’s observed or reported response. Keep diagnostic and progress interpretation for Assessment.
- Document client-reported auditory or visual hallucinations including frequency and intensity.
- Note any delusional themes or fixed false beliefs expressed by the client.
- Record reported triggers or stressors that exacerbate psychotic symptoms.
- Describe observed mood states such as blunted, flat, or inappropriate affect.
- Capture client’s description of functional impairments related to symptoms (e.g., social withdrawal).
Assessment
Provide clinical analysis, treatment progress, and diagnostic considerations
In Assessment, interpret what you recorded in Data: diagnostic impressions, symptom severity and change, function, insight, progress toward treatment goals, early warning signs of relapse and risk.
- Evaluate the severity and impact of positive and negative symptoms based on clinical observation.
- Assess client’s insight and judgment regarding their illness and symptoms.
- Interpret what the client’s response to cognitive-behavioral therapy for psychosis (CBTp) or other interventions recorded in Data means for symptoms, coping and goals.
- Note any early warning signs of relapse and how they change your clinical judgment of current stability.
- Provide clinical impression regarding symptom progression or remission since the last session.
Plan
Document next steps, interventions, and follow-up scheduling
The Plan section for schizophrenia should detail the next steps in treatment, including specific interventions, homework assignments, medication management considerations, referrals, and scheduling of upcoming sessions.
- Outline adjustments to therapeutic approach based on client’s current symptomatology.
- Assign homework focused on coping strategies for managing hallucinations or delusions.
- Coordinate referrals to psychiatry for medication evaluation or adjustment if needed.
- Schedule follow-up appointments and specify frequency based on acuity of symptoms.
- Plan for incorporation of family psychoeducation or social skills training as appropriate.
SOAP Notes for Schizophrenia
Alternative format for documenting schizophrenia
BIRP Notes for Schizophrenia
Alternative format for documenting schizophrenia
Progress Notes for Schizophrenia
Alternative format for documenting schizophrenia
SIRP Notes for Schizophrenia
Alternative format for documenting schizophrenia
GIRP Notes for Schizophrenia
Alternative format for documenting schizophrenia
PIE Notes for Schizophrenia
Alternative format for documenting schizophrenia
Example DAP note for schizophrenia (CBT for psychosis)
Fictional documentation example, not treatment guidance. Every detail is invented. Adapt it to the session you actually provided and your organization’s requirements.
Session details: Fictional adult client, 29, schizophrenia (F20.9), first diagnosed at 22, one hospital admission 3 years ago. Session 9 of weekly cognitive behavioral therapy for psychosis (CBTp), 50 minutes, in person at a community mental health clinic. Monthly long-acting injectable antipsychotic, prescribed and given by the clinic psychiatrist. Lives with his mother. Treatment-plan goals: (1) reduce distress from voices to 4/10 or less; (2) attend his part-time job 3 days a week; (3) a written relapse plan shared with his mother.
Data: Client reports hearing a male voice several times a day saying “you’re useless” and “they’re laughing at you,” mostly in the evening; distress 6/10 (9/10 at intake). Denies voices telling him to harm himself or others. Still believes, about 50% (90% at intake), that coworkers can hear the voice. Worked 3 shifts this week. Sleeping 7 to 8 hours. Smoked cannabis once this week (most days at intake). Reports receiving his injection on schedule last week; mild restlessness, which he has told the psychiatrist about. Asked directly: denies suicidal thoughts, plan or intent now and since the last session; one past suicide attempt by overdose at 23, before treatment began; no firearms at home; his mother keeps household medicines. PSYRATS auditory hallucinations: 22 (30 at intake). Mental status: casually dressed, good hygiene; mildly restless; affect slightly restricted; speech normal; thought process mostly linear, briefly tangential once; no evidence he was responding to voices in session; oriented. Interventions: reviewed the voice diary; discussed the belief that coworkers hear the voice and agreed to design a collaborative behavioral experiment at the next session (no experiment was done today); made a coping card (“The voice says useless. I worked 3 shifts.”); began a relapse-signature plan listing his early warning signs (sleeping under 5 hours, staying in his room, feeling that the TV is about him).
Assessment: Schizophrenia, improving: PSYRATS down 8 points, distress from voices down from 9 to 6/10, conviction that others hear the voice down from 90% to 50%, and goal 2 met this week. Insight partial: he accepts the voices may come from his illness on most days. Reduced cannabis use and stable sleep support stability; no early warning signs this week. Restlessness may be a medication side effect and is with the psychiatrist. Risk formulation: risk factors include schizophrenia, a past attempt, male sex and cannabis use; protective factors include no current suicidal thoughts, no command hallucinations, adherence, work, his mother’s support and engagement in treatment. Acute risk judged low. Reassess every session.
Plan: Continue weekly CBTp. Client chose to read his coping card when the voice starts and to record voice distress and belief conviction once each evening. Next session, collaboratively define a low-distress behavioral experiment, including the prediction, what would count as evidence, other explanations and a stopping plan; no coworker questioning was assigned. With his consent, invite his mother to the next session to finish the relapse-signature plan and agree what she will do if early warning signs appear. With his consent, tell the psychiatrist about his reported restlessness and the session summary. Repeat PSYRATS in 4 weeks. Client knows to call or text 988 in a crisis and to call 911 or go to the nearest emergency department for imminent danger.
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Tips for DAP Notes for Schizophrenia & Psychotic Disorders
Describe voices and beliefs specifically
Record content, frequency, distress and the client’s conviction, with a short quote. “AH present” alone does not show change.
Always record command hallucinations
Note whether voices tell the client to harm themselves or others, the content and whether they intend to act on them.
Write down insight and early warning signs
Record how the client understands their experiences and any signs from their relapse signature, such as poor sleep or withdrawal.
Note substances and sleep
Cannabis and other substances, and short sleep, affect relapse risk. Record amounts and changes.
Keep medication with the prescriber
Record reported adherence and side effects and your consented contact with the prescriber. Do not record dose advice in a therapy note.
Use a repeated measure
A scale such as the PSYRATS shows which part of the voice experience is changing, such as distress or conviction.
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Further Reading
- DSM-5-TR — Provides the diagnostic criteria and classification for Schizophrenia and Psychotic Disorders essential for accurate clinical assessment.
- APA Documentation Guidelines — Offers detailed guidance on clinical documentation practices relevant to mental health professionals using formats like DAP notes.
- SAMHSA — Contains resources and best practices for treatment and documentation of serious mental illnesses including Schizophrenia.