Clinical Documentation Guides
Pick a note format below. Each hub shows 72 diagnosis-, specialty-, and setting-specific guides with real example notes.
SOAP Notes
Subjective · Objective · Assessment · Plan
The universal medical-style format, accepted by every payer. Most widely used in mental health.
Explore 72 SOAP guidesDAP Notes
Data · Assessment · Plan
Faster than SOAP. Popular in outpatient talk-therapy where Subjective/Objective split feels artificial.
Explore 72 DAP guidesBIRP Notes
Behavior · Intervention · Response · Plan
Favored in behavioral health, substance-use treatment, and settings where demonstrating active intervention matters.
Explore 72 BIRP guidesSIRP Notes
Situation · Intervention · Response · Plan
Used in crisis stabilization, case management, ACT teams. Emphasizes the trigger event for the contact.
Explore 72 SIRP guidesGIRP Notes
Goal · Intervention · Response · Plan
For CARF-accredited programs and payers requiring session-by-session treatment-plan goal linkage.
Explore 72 GIRP guidesPIE Notes
Problem · Intervention · Evaluation
Brief nursing-originated format. Fast to write, suited to inpatient and group program settings.
Explore 72 PIE guidesProgress Notes (All Formats & Narrative)
Umbrella: any structured format or free-form narrative
The term for routine clinical session documentation. Covers when to use a structured format vs. narrative, and what elements are legally required regardless of format.
Explore 72 Progress Note guidesNot sure which format to use?
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