It’s an image we’re all too familiar with; the patient sits comfortably and details their entire life story, while the therapist listens, and scribbles something down on a piece of paper. We’re so accustomed to this image, that movies and TV shows often poke fun at it. Sometimes you’ll see the fictional character frantically asking their therapist what they wrote or changing their answer to offer the correct idea.
But what and who are those notes for?
Are they for the therapist, as a way for them to remember important details from the session? Are they for the patient?
The answer is both. Note-taking is an essential part of the mental health industry, because it links to the overall treatment plan of the patient. Some clinicians choose other methods to capture a session, such as video and audio recordings, but note-taking during the session is the first step. After that, therapists write progress notes, commonly done using the BIRP notes format.
Why are Clinical Records Important?
Many practitioners agree clinical records are a critical piece of offering quality mental health solutions. As a general rule, documentation helps ensure the continuity of care and improves communication between different healthcare professionals.
Routinely updated records provide much-needed information to all parties involved in the client’s care. This is especially true when multiple professionals must oversee the same case. Proper and timely documentation ensures that each person understands the current case.
In a standard medical setting, proper documentation is often lifesaving. For example, without the previous physician recording a patient’s allergy to a particular drug, the next doctor may make the mistake of administering that drug. The patient may forget, or not be able to tell the doctor they are allergic, in which case their conditions can get worse. Proper documentation helps to reduce the likelihood of these incidents.
While therapists and other medical personnel usually read patient documentation, they’re not the only ones. Sometimes third parties uninvolved in the direct care of the patient also need access. For example, in a court proceeding. Other times, they are required as part of the therapy intake process.
For example, if a patient moves out of state, and then works with another therapist, then the documentation from the previous one still is important to their course of treatment. The new therapist should know what the patient experienced before. Those notes should answer questions like, what type of treatment plan the client had, what worked, and what didn’t. Routinely updated clinical records offer continuity of care, even if the therapist changes.
Because of scenarios like these, it’s important to have a standardized model through which clinicians can write progress notes about and for their patients.
Six Elements of Clinical Records
Overall, client records should include the following,
- Patient information (age, gender, education, and other background information),
- Reason for seeking therapy (the mental health issue they are facing),
- Diagnosis and impression (from the perspective of the therapist),
- Clear treatment plan,
- Treatment details including medications administered, and;
- Progress reports.
What Are BIRP Notes?
BIRP notes are a model used by mental health professionals to track a patient’s progress. The acronym stands for “Behavior Intervention Response Plan.”
Put into practice, BIRP notes should look something like this:
- Behavior (Presenting the Problem)
In this section, we need observation of subjective and objective details. Subjective details refer to observations made directly by the client (their thoughts and/or opinions) Therapists often write these as direct quotes. Objective details refer to information about the client that the therapist notices (mood, appearance, etc.)
This section can also contain details about the session itself, such as where it took place. This can be relevant if the therapist is making house calls, or using a blended care approach (combining a traditional therapy session with digital therapy sessions).
Example: Met with client X in the office. The most recent assessment shows they are presenting symptoms of anxiety. Today they showed signs of exhaustion, lack of focus, and looked tired. They reported not being able to sleep in the past week and feeling overwhelmed by work.
This section outlines the methods used to reach the goals and objectives of the therapy. It’s a concise summary of the conversation, focusing strongly on the therapist’s actions and the patient’s reactions.
Example: Through client-centered techniques, this writer encouraged the patient to expand their thoughts about their work. Negative thoughts were identified and challenged. The patient was asked to see if there is a link between their insomnia and the stressful period at work. The connection was successfully made and normalized through discussion. The conversation then focused on the specific work-related triggers that may have lead to insomnia. A mild sleep aid was prescribed.
In this section, the therapist should record the client’s response to the intervention, including what the client said and how they reacted.
Example: The patient initially rejected the link between their insomnia and stress at work. When asked how work made them feel, the patient became silent, reduced eye contact, and disengaged from the conversation with the writer. After a few moments of thinking, the patient was able to describe their own feelings in relation to their work.
The plan outlines when the next session will take place, and its focus.
Example: The next appointment scheduled for September 16, will assess the client’s response to the sleep aid and reassess their feelings about work.
The Alameda County Behavioral Health organization offers a handy checklist outlining the questions therapists can use for each section of their BIRP notes.
Some institutions show a clear preference for using BIRP notes. For instance, Solano County MHP issued a documentation manual in which they recommend using the BIRP progress notes, saying it may “not be the best thing since sliced bread, but in the auditing world it comes pretty close.” Other organizations choose different progress reporting formats.
SOAP and DAP Models
The BIRP note format is a common model for progress reporting in the mental health sector, but it’s not the only one. There is no federal or international rule establishing the use of one model over another. Mental health coaches and therapists are free to choose whichever format for progress reporting they prefer. There is a general idea that, at least at the institutional level, therapists should adopt and use the same model.
SOAP notes include four sections. They are,
- Subjective – The therapist records information relevant to what the client shares during a session.
- Objective – This section includes factual information, such as a diagnosis, or other observations made by the therapist.
- Assessment – These are impressions and interpretations of the subjective and objective information made by the therapist. It’s like an analysis of the previous information, in which the professional may assess risk or the client’s progress towards their goals.
- Plan – In the last section, the therapist outlines the next steps for the sessions and client.
If this approach appeals to you, check out Susan Cameron’s and Imani Turtle-Song’s paper titled, Learning to Write Case Notes Using the SOAP Format.
The DAP model brings together the subjective and objective information under a section called data. The other two areas are assessment and plan. Sometimes using DAP notes is a simpler way for new therapists to capture the various components of a session.
What Do The Models Have in Common?
All these models account for the same type of information needed for progress reporting. As important psychology tools, they each help therapists achieve the same goals — structuring their notes efficiently. Long paragraphs may encourage therapists to write irrelevant information about the client and the sessions.
This can make adjusting an overall treatment plan more challenging. The short, structured nature of these models makes note-taking simple and quick.
BIRP note-taking, or other models, is a way to organize information about the patient so that the therapist can easily follow their progress.
The American Psychological Association (APA) released guidelines for overall record keeping. These guidelines help therapists and mental health professionals ensure the proper storage and security of therapy notes. Through its guidelines, the APA also emphasizes respecting ethics regulations.
The guidelines are,
- Responsibility for Records: Therapists and psychologists are responsible for the maintenance and storage of the client’s records;
- Content of Records: Therapists must do whatever they can to ensure the records are accurate;
- Confidentiality of Records: The therapist must take reasonable measures to make sure all patient records are confidential;
- Disclosure of Record-Keeping Procedures: Therapists must inform the patient of the procedure in place for record-keeping, confidentiality guidance, and the limitations of confidentiality (meaning the instances where the therapist may need to disclose some information to third parties, such as law enforcement or insurance adjusters);
- Maintenance of Records: The therapist must organize and maintain records and ensure their accuracy;
- Security: The therapist must take reasonable measures to make sure all patient records are secure, and that unauthorized third parties cannot access them. Records also must be protected from damage;
- Retention of Records: The therapist must be aware of the relevant legislation pertaining to acquiring and storing patient information;
- Preserving the Context of Records: The therapist must always be aware of the situational context the records are created in;
- Electronic Records: Electronic records must meet the same legal and maintenance requirements as paper records;
- Record Keeping in Organizational Settings: Therapist working in hospitals, schools, or other institutions or organization must keep the same model for recording agreed though the entire institution;
- Multiple Client Records: The therapist must offer special consideration to the recording process when designing mental health programs on a larger scale, or even simply in couples therapy, in order to respect the privacy and confidentiality of all parties involved;
- Financial Records: Therapists must ensure the accuracy of all financial records;
- Disposition of Records: If the patient changes therapists, the professional who initially created the patient record is responsible for transferring them to ensure the patient’s continuity of treatment.
BIRP Notes and Technology
These days, therapists have a more efficient and easy way to keep notes of their sessions, whether they choose the BIRP, SOAP, DAP, or any other model. The availability of a variety of specialized apps and therapy notes software facilitates this process.
The benefits of using specialized documentation software to take BIRP notes could be:
- Improved care – Many apps and programs include customization features. Th is helps the therapists adjust the app to meet their needs and the client’s goals. This way, BIRP notes can provide even more insights to therapists, who can then offer better care for their patients,
- A better overview of patients – When the records are digital, it’s also a lot easier to spot any mistakes or unnecessary repetitions. Many medical software solutions can generate detailed reports based on the introduced data, which a therapist can quickly review; and,
- Faster note-taking – Many programs can streamline the entire note-taking process through pre-defined templates. A common feature of both private practice and e-clinic software, templates come with structured sections, ultimately save the therapist time. Therapists can choose the sections that apply to their client, instead of writing them from scratch.
Taking notes is an essential part of therapy. Whether you follow BIRP, SOAP, DAP, or some other model, choosing the best one for your public or private practice depends on two considerations,
- What is the consensus in the institution or organization where you work (if applicable)?
- What is your preference?
Regardless of the format preferred, it’s essential for any record-keeping to respect ethical guidelines, as established by the APA.
- ^ Mathioudakis, A., Rousalova, I., Gagnat, A. A., Saad, N., & Hardavella, G. (2016). How to keep good clinical records. Breathe (Sheffield, England), 12(4), 369–373.https://doi.org/10.1183/20734735.018016.
- ^ Alameda County Behavioral Health. (2018). B.I.R.P. Progress Note Checklist. Retrieved from http://www.acbhcs.org/providers/QA/docs/2013/TR_BIRP_Progress_Note_Checklist.pdf
- ^ Cameron, K. & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling & Development, 80(3), 286-92.
- ^ American Psychological Association. (2007). Record Keeping Guidelines. Retrieved from https://www.apa.org/practice/guidelines/record-keeping