DAP Notes for Substance Use Disorders: Example and Template
How to write a DAP note for a substance use counseling session: what to document in Data, Assessment and Plan, a fictional worked example, and answers to common questions about relapse, severity, medication treatment and confidentiality.
Quick Answer
A substance use DAP note has three parts. Data: what the client reported since the last session (use of each substance with amount, frequency and date of last use, cravings, triggers, recovery activities, medication adherence if prescribed) and what you observed, including any signs of intoxication or withdrawal. Assessment: your interpretation: progress toward the treatment-plan goal, readiness to change, relapse risk and safety. Plan: homework, coordination and the next session.
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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Substance use notes need more precision than most: record use substance by substance, separate what the client reported from what you observed or tested, and keep your interpretation in Assessment. Use neutral, person-first language (“positive for,” not “dirty”). The table shows what goes in each section.
What to document in a substance use DAP note
| DAP section | What to document | Example wording |
|---|---|---|
| Data | Use since the last session, for each substance: amount, frequency, route if relevant, date of last use | “Reported alcohol use on 1 of 7 days (4 standard drinks on Saturday); last use 5 days ago. Denied other substance use.” |
| Data | Cravings, triggers and high-risk situations | “Cravings 3–4 times this week, peak 6/10, mostly after work. Trigger: family event where alcohol was served.” |
| Data | Recovery activities and, if prescribed, medication adherence as the client reports it | “Attended 2 mutual-help meetings. Reports taking prescribed medication daily; no missed doses or new side effects reported.” |
| Data | What you observed, and any test results your program uses | “Alert, speech clear, no signs of intoxication or withdrawal observed.” |
| Assessment | Progress toward the treatment-plan goal, compared with baseline | “Drinking days down from 4 a week at intake to 1; partial progress toward the goal of no alcohol use.” |
| Assessment | Readiness to change and relapse risk | “Remains in the action stage. Lapse occurred in a known high-risk situation; relapse-prevention plan needs an exit strategy for family events.” |
| Assessment | Safety and medical risk | “Denied suicidal thoughts. Denied withdrawal symptoms since last use. No current safety concerns identified.” |
| Plan | Homework, coordination (with consent where required) and next session | “Add exit plan for family events; attend 2 meetings; with written consent on file, update prescriber; next session in 1 week.” |
If the client reports heavy daily use, withdrawal symptoms, an overdose or suicidal thoughts, document the details, your risk assessment and what you did (for example a medical or withdrawal-management referral, overdose-prevention education, a safety plan or consultation), following your program’s protocol.
How to Document DAP Notes for Substance Use Disorders
Data
Combine subjective reports and objective observations into a single data section
When documenting the Data section for substance use, record the client’s self-reported symptoms, presenting concerns, and any contextual factors such as triggers and current mood or affect related to their substance use.
- Client’s description of substance cravings or withdrawal symptoms since last session
- Reported frequency, quantity, and type of substance use over the past period
- Identification of recent triggers or high-risk situations that led to or threatened substance use
- Client’s mood and affect during the session, noting signs of anxiety, depression, or agitation linked to substance use
- Any expressed concerns or goals regarding substance use shared by the client
Assessment
Provide clinical analysis, treatment progress, and diagnostic considerations
In the Assessment section for substance use, document clinical observations, the therapeutic techniques employed, your clinical impressions of the client’s status, progress towards treatment goals, and any diagnostic considerations.
- Observation of client’s physical and emotional state indicating intoxication or withdrawal
- Use of motivational interviewing or cognitive-behavioral techniques during the session
- Clinical impression regarding client’s readiness to change or stages of recovery
- Evaluation of progress toward substance use reduction or abstinence goals since last session
- Consideration of co-occurring mental health diagnoses or complications affecting substance use
Plan
Document next steps, interventions, and follow-up scheduling
The Plan section for substance use should outline the next steps in treatment, including homework assignments, any changes to the treatment approach, referrals, and scheduling of future sessions.
- Assignment of specific coping skills or behavioral tasks to practice before the next session
- Adjustment of treatment modalities or focus based on current client needs and progress
- Referral to specialized services such as detoxification, psychiatric evaluation, or peer support groups
- Scheduling of follow-up appointments or more frequent monitoring if clinically indicated
- Planning for relapse prevention strategies and crisis management in case of substance use episodes
DAP note example for substance use
Fictional documentation example, not treatment guidance. Adapt it to the session you actually conducted and your organization’s requirements.
Data: Fictional adult client, individual session 8 in outpatient treatment for alcohol use disorder, moderate. Treatment-plan goal: no alcohol use, measured by drinking days a week (4 a week at intake). Client reported one drinking day since the last session: 4 standard drinks at a family event on Saturday; last drink 5 days ago. Denied other substance use. Cravings 3–4 times this week, peak 6/10, mostly after work. Attended two mutual-help meetings. Client stated: “I stopped after the toast and left early, but I still drank.” Alert and oriented, speech clear, no signs of intoxication or withdrawal observed; client denied tremor, sweating or nausea since Saturday.
Assessment: Partial progress toward the goal: drinking days down from 4 a week at intake to 1. The lapse happened in a known high-risk situation (family event with alcohol available), and the client used part of the plan by leaving early. Client remains in the action stage and described the lapse as something to learn from. Screened for suicidal thoughts: denied. No current safety concerns identified.
Plan: Updated the relapse-prevention plan with an exit plan and a support contact for family events. Practiced urge surfing for after-work cravings. Client will attend two meetings and log cravings (time, trigger, peak 0–10). With the client’s written consent on file, clinician will update the client’s prescriber on progress. Next session in one week to review the craving log.
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Tips for DAP Notes for Substance Use Disorders
1. Record use by substance, not as a label
For each substance, record amount, frequency, route if relevant and date of last use. “Using less” or “polysubstance use” on its own cannot show change; “alcohol on 1 of 7 days, 4 drinks; denies other substances” can.
2. Keep severity and remission specifiers current
DSM-5-TR rates substance use disorder severity by the number of criteria met in a 12-month period: mild (2–3), moderate (4–5) or severe (6 or more). Early remission means that, after the full criteria were previously met, no criteria other than craving have been met for at least 3 months but less than 12 months; sustained remission uses an interval of at least 12 months. “In a controlled environment” and, where applicable, “on maintenance therapy” are separate specifiers, not evidence of remission by themselves. Check the criteria for the specific substance use disorder and update the diagnosis when the client’s status changes.
3. Document medication treatment neutrally
If the client takes medication for opioid or alcohol use disorder, such as buprenorphine, methadone or naltrexone, record adherence, side effects the client reports and coordination with the prescriber, without judging the treatment choice. Unless you are the prescriber, leave medication decisions to the prescriber.
4. Use measures the same way each time
If your program uses a screening or outcome measure (for example the AUDIT, the DAST-10 or a timeline followback), record the score or count and the date, not the items, and repeat it at set points. Withdrawal scales such as the CIWA-Ar are usually completed by medical or trained staff as part of withdrawal management, not as a counseling progress measure.
5. Treat a lapse as clinical information
In Assessment, say what the lapse or progress means for the plan: the trigger, which parts of the relapse-prevention plan held and any safety or medical risk. Use neutral, person-first language such as “positive for” and “person with a substance use disorder” rather than “dirty,” “clean” or “addict.”
6. Check which confidentiality rules apply
42 CFR Part 2 applies to records of federally assisted substance use disorder programs, not to every clinician who treats substance use. Where it applies, records carry extra protection and many disclosures need the patient’s written consent. Ask your program or compliance lead whether Part 2, HIPAA, state law or a combination governs your notes.
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Further Reading
- SAMHSA — Provides comprehensive resources and guidelines on substance use disorder treatment and documentation standards.
- DSM-5-TR — Offers diagnostic criteria essential for accurate assessment and documentation of substance use disorders.
- APA Documentation Guidelines — Details best practices for clinical documentation, including note structuring relevant to mental health and substance use cases.