May 23, 2024

Behavioral Healthcare Client Progress Notes: Examples for DAP, BIRP, & SOAP Formats

Behavioral Healthcare Client Progress Notes: Examples for DAP, BIRP, & SOAP Formats

As a mental health professional, you know that clear, concise, and accurate progress notes are essential in tracking a patient's treatment journey. 

Writing fully detailed notes after every session can be time-consuming for professionals. Luckily, many templates and software programs are available to help simplify the documentation process. 

In this overview, we'll help you understand the purpose of progress notes and equip you with the tools to write them effectively.

Table of Contents

Ritten: EMR Software for Behavioral Health With Highly-Customizable Form-Building for Progress Notes

When it comes to writing progress notes, there aren’t many software systems on the market that give healthcare professionals the flexibility to build forms in the way that they want or have to do them. EMRs are often a burden for providers, used only for compliance rather than as a powerful tool for documentation and analysis. 

At Ritten, we aim to lead the transformation to better behavioral health software. 

Our innovative, HIPAA-compliant EMR software comes with an intuitive documentation interface that allows you to customize everything to your needs; from notes to assessments to treatment plans. 

Beyond its form-building abilities, Ritten’s software also simplifies the process of maintaining:

  • Complex schedules 
  • Client progress tracking
  • Compliance with CARF and The Joint Commission
  • And more

Ritten is easy to use and has a dedicated onboarding team and account managers ready to help a facility seamlessly implement a new EMR or migrate from an old EMR system.

What Are Progress Notes?

Mental health progress notes are formal treatment records used by clinicians to document the details of each session with a client. 

Progress notes differ from therapy notes. Therapy notes are private records recorded by mental health professionals to capture key points and personal impressions. They may include a client’s personal details and the clinician’s private thoughts or hypotheses that are not appropriate to share with others. 

Progress notes record more in-depth, factual information that can be shared with insurance companies, accreditors, or other clinicians. They include details such as:

  • The client’s basic information
  • The client’s condition and notable changes since the previous visit
  • Treatment intervention and techniques used to address the client’s concerns
  • The client’s response to treatment
  • The client’s progress toward treatment goals

What Do You Write in a Progress Note?

The content of mental health progress notes may vary by state, licensing board, insurance company, or professional organizations that you belong to. Progress notes prove to accreditors that care is being provided following the client's treatment plan. 

Progress notes should always be factual and appropriate to share with others. The information recorded should include the following:

Demographic Information

  • Provider name and signature 
  • Client’s full name and date of birth
  • Session number, date, time, location, and duration of the session
  • Client’s diagnoses and applicable service codes

Notes on Client Behavior

  • The client's current condition or chief complaint. Include a description of the client's mental state and relevant observations of their mood, appearance, and actions. 
  • Any aspects that may pose a threat to the client's safety. These may include suicidal thoughts, self-harm habits, or unsafe living conditions. 
  • Pertinent test results or prescribed medication. Record any potential impacts on the client's symptoms and medication side effects.

Treatment Plan

  • Description of the methods, techniques, and interventions used during the session and any homework assigned to the client. 
  • A summary of the client’s verbal and nonverbal responses to the interventions discussed during the session. 
  • An outline of the client’s treatment plan going forward. This may include detailing the intended direction of treatment, the client’s progress toward treatment goals, future topics to explore, or potential interventions to try. 

3 Common Progress Note Formats With Examples

There are several common progress note templates that effectively combine descriptions of a patient’s behavior, assessment, and treatment plan. 

The three most widely used formats include:

  • Description, Assessment, Plan (DAP)
  • Behavior, Intervention, Response, Plan (BIRP)
  • Subjective, Objective, Assessment, Plan (SOAP)

Below is a helpful guide summarizing each template’s content and distinguishing features to help you decide the right system for your practice. 

To help you visualize each format, we've created condensed progress note examples under each description. Keep in mind that our progress notes will be longer and more elaborate than the examples provided.

#1: Description, Assessment, Plan

Description: This section should include a factual, objective account of the session, including the client’s mental status and symptoms. Some examples of what to have in the data are:

  • The client’s presenting problem
  • The client's mental state, mood, appearance, and hygiene
  • Quotes from the client
  • Any interventions used in your previous session and the client’s response
  • Screener results

Assessment: The assessment section is where the clinician interprets and analyzes information observed during the session. This typically includes:

  • The client’s diagnosis and any related changes
  • Any progress or regression regarding the client’s treatment goals
  • Changes to the client’s treatment goals
  • Evaluation of self-harm, homicidal, or suicidal risk

Plan: This section outlines the next steps in the client’s treatment plan. This may include information such as:

  • Client homework
  • Topics or techniques to be explored in future sessions
  • Changes in the client’s treatment plan
  • Any referrals to other professionals or organizations
  • The date and time of the next session

DAP Progress Note Example 

The following is a fictional DAP progress note example for a client named John, who is seeking treatment for symptoms of depression. 

  • Description: John arrived on time for our session to address symptoms of depression. John had a slightly disheveled appearance and was dressed appropriately. John improved two points on the PHQ-9, scoring in the moderate range. He has been compliant with his depression medication and says that symptoms are reduced, but still presenting. He reports slightly improved sleeping and hygiene habits. He spoke about a lack of interest in his work and personal life, stating that he “doesn’t feel excited” about upcoming opportunities. John was attentive during our session and expressed a desire for “everything to get back to normal.”
  • Assessment: John was an active and engaged participant during this session and responded well to interventions. His compliance with medication is evidenced in his improved sleep and hygiene habits, suggesting progress toward the treatment goal. He does not have any thoughts of suicide, homicide, or self-harm. 
  • Plan: John will return for our next session next Friday at 2:00 p.m. For homework, John was instructed to engage in one activity he used to enjoy. He will continue attending weekly sessions and taking medication as directed by his primary care physician.

#2: Behavior, Intervention, Response, Plan

Behavior: This section includes both objective and subjective information regarding the client. Record observations of the client’s behaviors, thoughts, experiences, and reported symptoms. 

Intervention: This section describes the mental health professional's response to the client's behavior. It details the client's condition, session content, and methods and techniques to address the client's problems.

Response: This section describes the client’s response to the therapist’s interventions. Was the client receptive to the therapeutic technique? Did they agree or disagree with the therapist’s methods? How did they respond to the treatment plan as a whole?

Plan: This section outlines the next steps for treatment. 

It may include:

  • Client homework
  • Topics or techniques to explore in future sessions
  • Changes in the client’s treatment plan
  • Any referrals to other professionals or organizations
  • The date and time of the next session

BIRP Progress Note Example 

The following is a fictional BIRP progress note example for a client named John, who is seeking treatment for symptoms of depression. 

  • Behavior: John presented on time for a session to address symptoms of depression. He appeared clean, neatly dressed, and fully oriented. He presents with a monotonous tone and reports feeling apathetic. He states he "doesn't get excited like he used to about get-togethers with friends." John did not display any risk of suicide, homicide, or self-harm. John reported that symptoms have slightly improved since our last session. 
  • Intervention: The therapist supported the client through talk therapy, discussing ways to restructure negative thought patterns. John plans to engage in one activity that he used to enjoy before our next session. 
  • Response: John reported feeling relieved after working through the source of his anhedonia and was receptive to behavioral action. 
  • Plan: John will return for our next session next Friday at 2:00 p.m. For homework, John was instructed to engage in one activity that he used to enjoy. He will continue attending weekly sessions and taking medication as directed by his primary care physician.

#3: Subjective, Objective, Assessment, Plan

Subjective: This section focuses on the client’s feelings, experiences, and concerns. It should describe:

  • The client’s chief complaint or presenting problem
  • History of present illness
  • Medical and family history
  • Any related social or environmental factors
  • Review of symptoms
  • Allergies and current medications

Objective: This section records any tests or factual data collected during your session. Details may include:

  • Vital signs
  • Test results
  • Physical examination findings
  • Records from other physicians

Assessment: This section is where the healthcare professional combines the information described in the subjective and objective sections above. It may include a diagnosis, differential diagnosis, patient progress, and potential risk factors or complications. 

Plan: This section describes future treatment steps such as CBT, medication, psychoeducation, or alternative mental health solutions. 

SOAP Progress Note Example

The following is a fictional SOAP progress note example for a client named John, who is seeking treatment for symptoms of depression. 

  • Subjective: John reports a lack of energy, poor sleep, and loss of interest in activities this week. He has experienced symptoms for four months and reports a family history of depression. 
  • Objective: John arrived on time but appeared disheveled with noticeable dark circles under his eyes. His speech was slow, and he maintained a monotonous tone throughout the session.
  • Assessment: John's self-reported fatigue, anhedonia, sleep disturbances, and low mood combined with in-session observations indicate Major Depressive Disorder. John has been compliant with medication for two months but has only seen partial improvements in depressive symptoms. 
  • Plan: Recommend a medication reevaluation with a psychiatrist and bi-weekly therapy sessions, incorporating CBT to treat depressive symptoms. Also recommended patients engage in social activities between sessions.

Progress Note Writing Tips

Laws, regulations, and requirements may dictate the specific content of progress notes. Still, you can follow some general rules to ensure that you maintain high-quality records throughout your practice.

Here’s a list of do’s and don’ts to consider when writing progress notes:

Do:

  • Remain objective. Document facts, observable behaviors, and direct statements made by the client in addition to subjective descriptors. Objective progress notes are more valid with insurance companies, accreditors, court systems, and other professionals. 
  • Be clear and concise. Consider if your two-paragraph description can be trimmed down to two sentences instead. Only use unnecessary jargon that may be difficult for other professionals to understand if it is relevant to the field and essential for the note. 
  • Use a progress note template. Utilizing templates such as DAP, BIRP, or SOAP ensures consistent note-taking that is easy for other professionals to access and understand. 
  • Document electronically using a secure platform. Consider using electronic management software (EMR) to manage and organize your practice's progress notes. EMR software helps ensure consistency, efficiency, care coordination, and easy record access.

Don’t:

  • Write excessive notes during your session. Excessive note-taking can take your attention away from the client during your session. In addition, overly detailed descriptions may be too wordy and irrelevant to treatment. 
  • Include excessive detail. Remember that progress notes may be shared with others. Be sure not to disclose any unnecessary personal and private information about the patient within your notes. 
  • Use judgmental statements. Be sure that all of your claims are backed up by objective evidence. Personal opinions regarding a patient are irrelevant to insurance companies, courts, and other professionals who may access your progress notes.

Make Progress Note Writing Simple With Ritten’s EMR System for Behavioral Healthcare

No matter what method you use for progress notes, Ritten makes the documentation process easy with customizable forms, assessments, and treatment plans for everyone in your practice. 

Our EMR software enables mental health professionals to:

  • Easily manage documentation 
  • Manage complex schedules with ease
  • Manage group note-taking and attendance from one screen
  • Maintain compliance
  • Better understand and monitor client progress and outcomes
  • Seamlessly order and administer medications
  • Drive referrals through better communication techniques

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