BIRP Notes for PTSD: Template + Examples (2026)
Overview
This guide is part of our complete BIRP notes hub — format structure, a full clinical example, the BIRP note generator, and all 72 diagnosis-specific templates.
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Short answer: a BIRP note for PTSD has four parts. Behavior: the client’s report of intrusions, avoidance, negative thoughts and mood, and arousal since the last session, what you observed, and scores such as the PCL-5. Intervention: the trauma-focused work you did and the goal it serves. Response: how the client responded, including distress ratings, dissociation and your view of progress and risk. Plan: the next session, any practice and when you will repeat measures.
BIRP has no separate assessment section, so many clinicians put their clinical judgment about progress and risk in Response. Keep the trauma history brief; the note does not need the full trauma account.
What to document in a BIRP note for PTSD
| Section | What to document | Example wording |
|---|---|---|
| Behavior | Symptoms since the last session by symptom area, your observations, and scores with the comparison | “Nightmares 2 nights (4 at intake); avoids highway driving; PCL-5 45 (intake 56).” |
| Intervention | The treatment, session number and what was done | “WET session 3 of 5: 30 minutes of trauma writing with the session 3 instructions.” |
| Response | Distress ratings at the times the protocol sets, dissociation, how the client finished the session, progress and current risk | “SUDS 70 before writing, 50 after; no dissociation; acute risk low.” |
| Plan | Next session, practice if your protocol uses it, and repeat measures | “WET session 4 next week; PCL-5 then.” |
Safety. PTSD raises the risk of suicide, especially with depression or alcohol and drug use, so ask directly and record the answer. If a client reports suicidal thoughts, assess and record current thoughts, plan, intent, preparatory behavior, past attempts, access to means (including firearms and medications), protective factors, your risk formulation and the safety plan. If the client dissociates during trauma work, record what you saw, how you grounded them and that they were oriented before leaving. The 988 Suicide & Crisis Lifeline takes calls and texts at 988; for imminent danger, call 911 or go to the nearest emergency department.
How to Document BIRP Notes for Post-Traumatic Stress Disorder
Behavior
Document observable client behaviors, actions, and presentation in session
When documenting Behavior in PTSD, focus on capturing the client’s reported symptoms, observable emotional states, specific triggers encountered, and overall mood or affect during the session.
- Client reports frequency and intensity of flashbacks or intrusive memories
- Identification of specific environmental or interpersonal triggers discussed by the client
- Observation of hypervigilance or startle response during the session
- Description of client’s mood, including anxiety, irritability, or depressive symptoms
- Client’s report of avoidance behaviors related to trauma reminders
Intervention
Record specific therapeutic interventions and techniques used
Document the clinical techniques and therapeutic modalities applied during the session to address PTSD symptoms, including any adaptations made to meet the client’s current needs.
- Use of grounding techniques to manage dissociation or flashbacks
- Application of cognitive-behavioral strategies targeting trauma-related thoughts
- Implementation of relaxation or breathing exercises to reduce hyperarousal
- Introduction or continuation of exposure therapy elements tailored to client readiness
- Clinician’s observation of client engagement and affect regulation during interventions
Response
Note the client's response to interventions and observable changes
Capture the client’s reaction to the interventions, clinical impressions regarding symptom changes or stability, and any diagnostic considerations noted during the session.
- Client demonstrates increased ability to tolerate distressing memories without dissociation
- Noted reduction or persistence of avoidance behaviors since last session
- Client verbalizes insight into trauma-related thought patterns or triggers
- Clinician assesses symptom severity compared to previous sessions
- Client expresses feelings of empowerment or frustration related to treatment progress
Plan
Outline next steps, continued interventions, and session scheduling
Outline the next steps for treatment, including homework assignments, any recommended modifications to the therapeutic approach, referrals, and scheduling of subsequent sessions.
- Assign homework focused on practicing coping skills in real-world settings
- Plan to introduce trauma narrative work or EMDR in upcoming sessions
- Recommend referral to psychiatric evaluation for medication assessment if indicated
- Schedule next session to monitor symptom progression and adjust treatment accordingly
- Modify treatment goals based on client’s current symptom severity and readiness
SOAP Notes for PTSD
Alternative format for documenting ptsd
DAP Notes for PTSD
Alternative format for documenting ptsd
Progress Notes for PTSD
Alternative format for documenting ptsd
SIRP Notes for PTSD
Alternative format for documenting ptsd
GIRP Notes for PTSD
Alternative format for documenting ptsd
PIE Notes for PTSD
Alternative format for documenting ptsd
Example BIRP note for PTSD (Written Exposure Therapy)
Fictional documentation example, not treatment guidance. Every detail is invented. Adapt it to the session you actually provided and your organization’s requirements.
Session details: Fictional adult client, 41, PTSD (F43.10) after a highway crash in which she was seriously injured. Session 3 of 5 of Written Exposure Therapy (WET), weekly; treatment-plan goal: drive on the highway to work.
Behavior: Client reports nightmares about the crash on 2 nights this week (4 a week at intake), startling at loud traffic noise, and taking a 40-minute back-road route to avoid the highway. Says she felt “drained but calmer” for a day after the last session. PCL-5: 45 (intake 56). Tense at the start; speech normal; thought process linear; alert and oriented. Asked directly about suicide: denies thoughts of death or suicide, intent or plan; no past attempts; no firearms at home. Drinks 1 glass of wine on weekends; no drug use.
Intervention: Reviewed reactions since the last session and gave feedback on how the previous narrative followed the writing instructions. Delivered the session 3 instructions: write again about the crash, including its most distressing part, thoughts and feelings, and begin describing how it changed her life. Client wrote alone for 30 minutes. Afterwards, checked in about the experience of writing without conducting detailed verbal processing of the trauma narrative.
Response: SUDS 70 before writing and 50 afterwards. At the post-writing check-in, client reported no dissociative symptoms and said she had written more about the moment of impact than in earlier sessions, suggesting greater engagement with the memory. No dissociation observed during the check-in; alert and oriented before leaving. Nightmares are less frequent. Progress toward the highway-driving goal has not yet been demonstrated: she continues to avoid the highway and uses the back-road route to work. Acute suicide risk judged low: no current suicidal thoughts, intent or plan, no past attempts, no firearm access; protective factors include her children and engagement in treatment.
Plan: WET session 4 next week. WET has no between-session assignments. Encouraged the client to allow trauma-related thoughts, feelings and memories to arise without trying to avoid them. Repeat PCL-5 at session 4. Review the highway-driving goal after session 5. Client knows to call or text 988 in a crisis and to call 911 or go to the nearest emergency department for imminent danger.
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Tips for BIRP Notes for Post-Traumatic Stress Disorder
Organize Behavior by symptom area
Group what the client reports into intrusions, avoidance, negative thoughts and mood, and arousal, with counts where possible.
Name the protocol and session
Write the treatment and session number, such as “WET session 3 of 5,” so the record shows where the client is in care.
Record distress ratings in Response
Record distress ratings at the times specified by the treatment protocol. In WET, record SUDS before and after the writing period without interrupting the writing to obtain a peak rating.
Note dissociation and grounding
Record any dissociation, what you did to ground the client and that they were oriented before leaving.
Put your judgment in Response
BIRP has no assessment section. Record your view of progress and risk in Response.
Repeat the PCL-5
Give it at a regular interval and write each score next to the earlier one so change is visible.
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Further Reading
- DSM-5-TR — Provides standardized diagnostic criteria for PTSD essential for accurate clinical documentation.
- SAMHSA — Offers evidence-based resources and guidelines for treatment and documentation of trauma-related disorders.
- APA Documentation Guidelines — Details best practices for clinical documentation, including note formats like BIRP, relevant to mental health professionals.