Progress Note Formats

When using AI-Assisted Progress Notes, you can choose the Progress Note Template that best suits your agency. Below is a brief explanation of the available types.

SOAP

Available for individuals & couples

SOAP stands for Subjective, Objective, Assessment, and Plan. This note type is oriented towards effectively tracking the client’s progress, thoughts, behavioral changes, and subjective experiences, as well as facilitating therapeutic insights and enabling effective planning for the next session.

SOAP notes are suited to medicine in general because the subjective and objective sections are separate. However, in mental health sessions, most likely only the physical presentation and assessment results can be recorded.

DAP

Available for individuals & couples

DAP stands for Data, Assessment, and Plan. It combines subjective and objective data in one section and primarily focuses on the client’s goals and the interventions used to address those goals.

Many mental health professionals prefer the DAP note because it doesn't require the categorization of information as objective or subjective and they can simply include everything as data.

GIRP

GIRP stands for Goals, Intervention, Response, and Plan. It helps therapists focus on the specific goals and objectives identified by the client for their therapy. The GIRP format outlines the therapeutic interventions and techniques used, evaluates their effectiveness, and facilitates planning for continued progress and growth.

GIRP-formatted notes are perfect for when a client and mental health professional have defined a clear goal together. It helps show the client their ability to make small steps toward larger objectives, offering encouragement.

BIRP

BIRP stands for Behavior, Intervention, Response, and Plan. BIRP notes include the subjective and objective data from your session in one place, the Behavior section. By outlining the therapist's interventions based on client behavior and capturing the client's subsequent responses, this format highlights the role of the therapy in the client’s progress.

BIRP notes are especially useful in the behavioral health field. This format focuses on the effectiveness of therapy and is also helpful for studying therapist behavior.

EMDR

EMDR stands for Eye Movement Desensitization and Reprocessing, which is a therapy technique. This approach is primarily used to treat PTSD and traumatic events. EMDR notes may include details about the client’s emotional and physical responses, shifts in beliefs or perceptions, and any insights gained during the session.

EMDR notes allow for very detailed tracking of traumatic memories, associated cognition and emotions, and a scale for the validity of the image/incident itself. Accompanying emotions are rated and located in the body, followed by bilateral stimulation and desensitization.

Mental Status Exam

The MSE is a standard tool used by clinicians to assess the basic functioning of a client. The assessment categories include mood, cognition, perception, thoughts, behaviors, insight, and judgment.

Standard intake

Use Intake notes during an intake session to automatically capture answers to standard questions such as personal and social history, family background, and any previous treatment received.

Psychiatric SOAP

Includes important MSE criteria under the Objective section to capture Appearance, Emotions, Thoughts, Cognition, Judgment, and Insight. This format identifies and spell checks medication names, captures dosages, changes, and side-effects, and also contains a lab results and risk assessment section.

Psychiatric intake notes

Use psychiatric intake notes during an initial patient evaluation for a complete psychiatric assessment. These notes capture chief complaints, mental status, family/social backgrounds, medical and substance histories, and DSM diagnoses leading to an informed treatment plan.