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

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/behavioral 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.

Frequently asked questions

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.

What should be in every therapy note?

Date/time, ICD-10 diagnosis, CPT code, clinical observations, interventions, patient response, treatment plan progress, plan for next session, and risk assessment when relevant. Format choice is structural; required content is the same.

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.