Guides by Note Format
Learn how to use each clinical documentation format. Choose a format below to explore guides for different specialties and settings.
SOAP Notes
Subjective, Objective, Assessment, Plan
SOAP notes are the most widely-used clinical documentation format in mental health settings. The four-section structure provides comprehensive documentation suitable for insurance reimbursement, legal review, and continuity of care.
DAP Notes
Data, Assessment, Plan
DAP notes offer a streamlined three-section format popular in community mental health and agency settings. The condensed structure prioritizes efficiency while meeting compliance requirements.
BIRP Notes
Behavior, Intervention, Response, Plan
BIRP notes emphasize the relationship between client behavior and clinician interventions. This format is particularly useful for behavioral therapy, child/adolescent therapy, and tracking specific behavioral changes.
Progress Notes
Clinical Progress Notes
Progress notes track client treatment over time, documenting session activities, client responses, and treatment plan updates. They are required for insurance reimbursement and continuity of care.
Guides by Specialty
Find documentation guides tailored to specific mental health conditions and treatment modalities.
Anxiety Disorders
Generalized anxiety disorder, panic disorder, social anxiety, phobias, and OCD documentation. Includes tracking worry pa...
Depression
Major depressive disorder, persistent depressive disorder, and seasonal affective disorder documentation. Includes mood ...
Trauma & PTSD
Post-traumatic stress disorder, complex trauma, and acute stress disorder documentation. Includes trauma processing prog...
Substance Use Disorders
Alcohol use disorder, opioid use disorder, and polysubstance use documentation. Includes sobriety tracking, relapse prev...
Couples Therapy
Couples and marriage counseling documentation for relationship issues, communication problems, infidelity, and co-parent...
Child & Adolescent Therapy
Therapy documentation for minors including play therapy, family involvement, school coordination, and developmental cons...
Group Therapy
Group psychotherapy documentation including individual progress within group context, group dynamics, peer interactions,...
Eating Disorders
Anorexia nervosa, bulimia nervosa, binge eating disorder documentation. Includes weight tracking, meal planning progress...
Bipolar Disorder
Bipolar I, bipolar II, and cyclothymic disorder documentation. Includes mood episode tracking, medication compliance, sl...
ADHD
Attention-deficit/hyperactivity disorder documentation for adults and children. Includes symptom tracking, medication ma...
Guides by Setting
Documentation requirements vary by practice setting. Find guides specific to your work environment.
Private Practice
Solo and small group private practice settings where therapists manage their own documentation, billing, and compliance....
Community Mental Health
Community mental health centers serving diverse populations with high caseloads. Documentation must meet agency standard...
Telehealth
Remote therapy sessions via video or phone. Documentation must note the modality used, participant locations, technology...
Hospital & Inpatient
Inpatient psychiatric units, partial hospitalization, and intensive outpatient programs. Documentation requires detailed...
School-Based Counseling
School counseling and therapy services for K-12 students. Documentation must coordinate with IEPs, 504 plans, and educat...
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