Therapy Notes Reference

Plain-language guide to clinical documentation formats, SOAP, BIRP, DAP, progress notes, with examples, templates, and the documentation requirements that support both reimbursement and clinical continuity.

Documentation formats

  • SOAP notes

    Subjective, Objective, Assessment, Plan

    The most widely used documentation format across medicine and behavioral health. Originated in the 1970s problem-oriented medical record (POMR) movement.

    Best for: General-purpose, multi-disciplinary settings, payer-friendly default

  • BIRP notes

    Behavior, Intervention, Response, Plan

    Behavior-focused format emphasizing what the clinician did and how the patient responded. Common in case management, substance-use treatment, and group programs.

    Best for: Case management, IOP/PHP settings, intervention-focused contexts

  • DAP notes

    Data, Assessment, Plan

    More concise three-part format collapsing subjective and objective data into one section. Common in private practice and outpatient psychotherapy.

    Best for: Private practice, outpatient psychotherapy, when conciseness matters

  • GIRP notes

    Goal, Intervention, Response, Plan

    Goal-led format that opens each note with the treatment-plan goal the session addressed, then records the interventions, the client's response and next steps.

    Best for: Goal-structured treatment, plan reviews, measurement-based care

What every progress note must contain

  • The format changes the headings, not the content. HIPAA's definition of psychotherapy notes keeps session times, modality and frequency, test results, diagnosis, symptoms, functional status, the treatment plan and progress in the clinical record; one Medicare contractor's policy (LCD L33252) asks psychotherapy notes to describe the interventions specifically and show progress toward measurable goals; and APA record-keeping guidance expects entries to be dated and attributable. In practice, every note carries:

  • Session details

    Client identifier, date, start and stop times, service (CPT code) and modality, including telehealth.

  • Diagnosis and symptoms

    The current diagnosis, symptoms and functional status, with any change since the last session.

  • Interventions

    What you did, described specifically. Under LCD L33252, an entry such as "supportive psychotherapy given" is not adequate; name the technique and what it targeted.

  • Response and progress

    How the client responded, and progress (or lack of it) toward the treatment-plan goals.

  • Test results

    Scale scores administered this session, with the severity band and the change from the last score.

  • Mental status and risk

    A brief mental status exam focused on change from baseline, and a risk assessment when indicated.

  • Plan

    Next steps, frequency, referrals, scales to re-administer, and the reason for any change to the treatment plan.

  • Signature

    The clinician's name and credentials, and the date the note was written.

  • Related guides: the mental status exam, treatment plans with measurable goals, and for the first session, intake notes (CPT 90791).

SOAP vs DAP vs BIRP vs GIRP vs PIRP

  • FormatSectionsOpens withWhere scale scores go
    SOAPSubjective, Objective, Assessment, PlanThe client's reportObjective (score and band); interpretation in Assessment
    DAPData, Assessment, PlanReport and observation togetherData; interpretation in Assessment
    BIRPBehaviour, Intervention, Response, PlanObserved behaviourBehaviour; administration can sit in Intervention
    GIRPGoal, Intervention, Response, PlanThe treatment-plan goalIntervention (administered); Response (change toward the goal)
    PIRPProblem, Intervention, Response, PlanThe treatment-plan problemIntervention (administered); Response (change on the problem)

    All five carry the same required content. Pick the one your payer, program or EHR expects and use it consistently. PIRP mirrors GIRP but opens with the treatment-plan problem rather than the goal; it has no page of its own here.

Progress notes vs psychotherapy notes, the HIPAA distinction

  • HIPAA recognizes two distinct categories of clinical documentation:

  • Progress notes

    Documentation of session content, interventions, treatment plan progress, and clinical decision-making. Part of the medical record. Accessible to insurance auditors, other treating providers (with appropriate authorization), and the patient.

    This is what you bill against.

  • Psychotherapy notes (process notes)

    The clinician's private reflections on the session, including hypotheses, transference dynamics, and personal reactions. Separately maintained from the medical record. Require specific patient authorization for disclosure under HIPAA, they are NOT routinely shared with auditors or other providers.

  • The distinction matters: most payers reimburse based on progress notes, not psychotherapy notes. Confusion or merging of the two can result in inappropriate disclosure, audit findings, or reimbursement disputes. Best practice: keep them in separate documents from session one.

Documenting MBC scale scores in notes

  • Sessions billing CPT 96127 (brief emotional/behavioural assessment with scoring and documentation) require each scale's score, clinical interpretation, and integration into the visit's decision-making to be documented in the note. Format-by-format, the integration looks different.

  • SOAP

    Score and severity band typically go in Objective; clinical interpretation and treatment-plan implication in Assessment.

  • BIRP

    Score administration and review go in Intervention; patient affective Response to score discussion follows.

  • DAP

    Score in Data; severity band, change from prior administration, and treatment-plan implication in Assessment.

  • See measurement-based care for the broader workflow context, or the assessment library for the underlying scales.

Measurement-based care

…starts with what we measure, and how long.

Frequently asked questions

  • What is a progress note in therapy?

    A progress note is the record of a single session: what was addressed, what the clinician did, how the client responded, progress toward treatment-plan goals, and the plan. It is part of the clinical record, unlike psychotherapy (process) notes. SOAP, DAP, BIRP and GIRP are different layouts for the same required content.

  • What format should I use for therapy notes?

    SOAP, BIRP, and DAP are the most common formats in mental health. SOAP is the most widely used; BIRP is favored in case management and substance-use treatment; DAP is concise and common in private practice. Choice depends on payer requirements, employer policy, and clinical context.

  • What's the difference between progress notes and psychotherapy notes?

    Progress notes are part of the medical record (used for billing and shared with auditors/providers). Psychotherapy notes are the clinician's private reflections, separately maintained, requiring specific patient authorization for disclosure under HIPAA.

  • Do I need to include scale scores in my notes?

    If you're billing CPT 96127, yes, each unit requires scale name, score, interpretation, and integration into clinical decision-making in the note. Beyond billing, longitudinal scale documentation supports MBC workflows and audit defense.

Sources & Citations

    1. 1.U.S. Department of Health & Human Services. HIPAA Privacy Rule and Sharing Information Related to Mental Health.
    2. 2.American Psychiatric Association. Documentation of Psychiatric Care: Guidelines for Clinicians.
    3. 3.American Medical Association. Current Procedural Terminology (CPT) 2026, code 96127 documentation requirements.
    1. 4.Centers for Medicare & Medicaid Services (Medicare contractor LCD). Local Coverage Determination L33252: Psychiatric Codes. Psychotherapy documentation requirements.
    2. 5.U.S. Department of Health & Human Services. 45 CFR 164.501, definition of psychotherapy notes (what stays in the record).
    3. 6.American Psychological Association. Record keeping guidelines. Am Psychol. 2007;62(9):993-1004. PMID 18085845.