Therapy progress note formats

A therapy progress note is the clinical record of one session: what happened, what the clinician concluded, and what comes next. SOAP, DAP, BIRP, PIRP and GIRP are five common ways to structure it. Medicare's contractors list what a note must contain, not which format it uses. What a reviewer checks is whether the note supports the service billed.

This guide covers each format with a short example, how to choose between them, what a progress note needs whatever its format, and how a progress note differs from psychotherapy notes under HIPAA.

The five formats at a glance

The examples below describe an invented client. They show structure, not clinical advice.

SOAP notes for therapists

SOAP comes from medicine, which is why psychiatric and integrated-care practices often use it.

• Subjective: what the client reports, in their words where it matters: mood, events since the last session, symptoms.
• Objective: what the clinician observes: appearance, affect, behavior in session, and scores from any measures given.
• Assessment: the clinician's interpretation: progress toward goals, risk, how the presentation relates to the diagnosis.
• Plan: next steps: interventions, homework, referrals, next session date.

Example. S: Reports worry most evenings since a family conflict last week. Sleeping about five hours. O: Alert, oriented, anxious affect, speech normal in rate. Engaged throughout the 53-minute session. A: Worry increased after a stressor. Uses the thought record with prompting. No safety concerns reported. P: Continue weekly CBT. New thought record focused on evening worry. Review sleep at the next session.

The weak point for therapists is the Objective section. Much of a therapy session is conversation, so observations are thinner than in a medical visit. Clinicians who find themselves padding it often switch to DAP.

DAP notes

DAP merges Subjective and Objective into one section, which makes it the shortest format.

• Data: what the client said and what the clinician observed, together. Include measure scores here.
• Assessment: the clinician's interpretation of the data: progress, risk, response to treatment.
• Plan: what happens next, including homework and the next appointment.

Example. D: Client reports evening worry since a family conflict and about five hours of sleep a night. Completed last week's thought record. Anxious affect, engaged, speech normal. A: Worry increased after a stressor. Able to identify one catastrophic thought and generate an alternative. No safety concerns reported. P: Continue weekly sessions. Assign a new thought record for evening worry. Review sleep next session.

A common mistake in DAP notes is repeating the Data section in the Assessment. The Assessment should say what the data means.

BIRP notes

BIRP puts the clinician's intervention in its own section. Settings that must show what the clinician did, and how the client responded, often require it.

• Behavior: the client's presentation and what they reported.
• Intervention: what the clinician did: the technique, the topic, the modality.
• Response: how the client responded to the intervention.
• Plan: next steps.

Example. B: Reports evening worry since a family conflict. Anxious affect, engaged. I: Reviewed the thought record. Used cognitive restructuring on the belief that the conflict will end the relationship. R: Identified the catastrophic thought and produced one balanced alternative. Rated belief in the original thought lower by the end of the session. P: New thought record for evening worry. Weekly session next Tuesday.

PIRP and GIRP notes

Both follow BIRP's shape. They change only the first section.

• PIRP opens with the Problem addressed in the session, usually a problem named on the treatment plan.
• GIRP opens with the Goal the session worked toward, usually a measurable goal from the treatment plan.

Both make it easy to show the link between a session and the treatment plan. That link is what reviewers look for when they ask whether a course of therapy is still necessary.

Which format to choose

• Use your program's format if it names one. Public programs have. Los Angeles County's Medi-Cal substance use system used BIRP, GIRP, SIRP and SOAP note forms until California's CalAIM documentation reform stopped requiring those formats.
• Use SOAP if your notes are read by medical providers, or if you prescribe.
• Use DAP if you want the shortest note that still separates observation from interpretation.
• Use BIRP, PIRP or GIRP if you need to show the intervention and the client's response, or tie each session to the treatment plan.

Consistency matters more than the choice. A reviewer reading twelve notes in the same structure can follow the course of treatment.

What a progress note needs, whatever the format

Medicare contractor coverage policies for psychotherapy ask the record to show:

• Time: the time spent in the psychotherapy encounter. The psychotherapy code is chosen by time, so this line decides the bill. See psychotherapy CPT codes.
• What was done: the type of service (individual, group, family, interactive) and the therapeutic techniques and approaches used, including medications.
• Why this treatment: the target symptoms, the goals of therapy and how outcomes are monitored, and why the chosen therapy is the right modality.
• Where it is going: a periodic summary of goals and progress toward them, and an updated treatment plan.

Each format has a place for all four. In SOAP and DAP, time and service type usually sit in a header line above the sections. In BIRP, PIRP and GIRP, the Intervention section carries the technique.

Psychotherapy notes are not progress notes

HIPAA uses "psychotherapy notes" for something narrower than a therapy note. Under 45 CFR 164.501, psychotherapy notes are a mental health professional's notes documenting or analyzing the conversation in a counseling session, kept separate from the rest of the medical record.

The same definition excludes the things a progress note records: medication prescription and monitoring, session start and stop times, the modalities and frequencies of treatment, results of clinical tests, and any summary of diagnosis, functional status, the treatment plan, symptoms, prognosis and progress to date.

The difference matters in two places:

• Disclosure. A covered entity needs the patient's authorization for almost any use or disclosure of psychotherapy notes (45 CFR 164.508(a)(2)). The narrow exceptions include use by the note's author for treatment.
• Patient access. Patients have a right to see and copy their record, including progress notes such as SOAP notes. That right doesn't extend to psychotherapy notes kept separately from the record (45 CFR 164.524(a)(1)(i); HHS guidance).

In practice: the progress note, in whatever format, is part of the record, and it's what supports the claim. Psychotherapy notes are optional, private and separate. Putting the clinical content a payer needs into psychotherapy notes, or putting process notes into the record, defeats both.

Where Caesar fits

Caesar's AI Scribe drafts the progress note in the format your practice already uses: SOAP, DAP, BIRP or your own template. The clinician reviews, edits and signs the draft. Caesar does not create psychotherapy notes. How Caesar works with psychiatry and therapy practices.