GIRP Notes for Substance Use Disorders
How to write a GIRP note for substance use: what goes in Goals, Intervention, Response and Plan, how to record use, drug screen results, readiness to change and overdose risk, with a fictional example.
Quick Answer
A GIRP note for substance use starts with the treatment-plan goal and the client’s goal for the session (Goals), then records what you did (Intervention), how the client responded, including use since the last session, drug screen results and readiness to change (Response), and the next steps, including safety and level of care (Plan).
Overview
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Short answer: a GIRP note for substance use has four parts. Goals: the treatment-plan goal this session works on, and the client’s own goal for the session in their words. Intervention: what you did, such as motivational interviewing, relapse-prevention skills or overdose education, and in a group, the topic and your role. Response: how the client responded, their report of use since the last session (each substance, amount, how often, route and last use), drug screen results, cravings and readiness to change. Plan: the next session, tasks, screening, referrals and any change in level of care.
Record facts, not labels such as “clean” or “dirty.” If your program is covered by 42 CFR Part 2, keep its consent rules in mind before sharing the record.
What to document in a GIRP note for substance use
| Section | What to document | Example wording |
|---|---|---|
| Goals | The treatment-plan goal and the client’s session goal | “Plan goal: no cocaine use for 30 days. Client’s goal today: ‘get through payday Friday.’” |
| Intervention | Methods used, group topic and your role, education given | “Led relapse-prevention group on high-risk situations; urge-surfing practice; reviewed naloxone and fentanyl risk.” |
| Response | Use since last session, screen results, cravings, readiness and participation | “Reports last use 16 days ago; Monday urine screen negative for cocaine; craving 6/10 before urge surfing, 3/10 after.” |
| Plan | Next steps, tasks, screening, referrals and level of care | “Payday plan; next random screen; individual session Thursday; continue intensive outpatient.” |
Safety. Record overdose risk: lower tolerance after a break, using alone, and illicit drugs, including cocaine and counterfeit pills, that may contain fentanyl. Record naloxone access and overdose education. Stopping alcohol or benzodiazepines suddenly can cause dangerous withdrawal, so route that to medical care. Substance use raises suicide risk; 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. For a suspected overdose, call 911 and give naloxone if available. 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 GIRP Notes for Substance Use Disorders
Goals
Document current treatment goals, client's goals for this session, and progress toward established objectives
When documenting goals for substance use, clearly outline the client’s targeted outcomes related to reduction, cessation, or management of substance use and associated behaviors. Goals should be specific, measurable, and tailored to the client’s stage of recovery and motivation.
- Establish short-term goals focused on immediate risk reduction related to substance use.
- Define long-term abstinence or controlled use objectives based on client readiness.
- Identify goals addressing co-occurring mental health symptoms that impact substance use.
- Set behavioral goals related to improving coping strategies and relapse prevention.
- Incorporate goals aimed at improving social support and engagement in sober activities.
Intervention
Record specific interventions applied to address identified goals and advance treatment
In the Intervention section, document the specific clinical techniques, therapeutic modalities, and observations applied during the session to address substance use. This includes any motivational strategies, counseling approaches, or assessments used to support the client’s recovery.
- Utilized motivational interviewing techniques to explore ambivalence toward substance use change.
- Applied cognitive-behavioral strategies to identify and challenge substance-related triggers.
- Conducted a brief substance use risk assessment or screening during the session.
- Engaged client in relapse prevention planning and skills-building exercises.
- Provided psychoeducation on the effects of substances and harm reduction approaches.
Response
Note the client's response to goal-focused work, progress indicators, and barriers to goal achievement
The Response section captures the client’s reactions, progress, and any clinical impressions related to their substance use during the session. Document changes in insight, motivation, affect, and any diagnostic considerations that emerged.
- Client demonstrated increased awareness of triggers contributing to substance use.
- Observed ambivalence or resistance toward behavior change regarding substance use.
- Noted improvement in coping skills or reported reduction in substance use since last session.
- Evaluated client’s readiness for next steps in treatment or potential need for higher level of care.
- Documented any new symptoms or concerns suggesting co-occurring disorders impacting substance use.
Plan
Specify action steps, revised goals if needed, and timeline for goal achievement
The Plan section should outline the next steps in treatment focused on substance use, including referrals, homework assignments, and modifications based on client progress and clinical observations. It also includes scheduling and coordination of care.
- Schedule follow-up sessions to monitor substance use patterns and recovery progress.
- Assign homework focused on tracking triggers and practicing coping strategies.
- Refer client to specialized substance use treatment programs or support groups as needed.
- Adjust treatment goals or modalities based on client’s response and engagement.
- Coordinate care with medical providers to manage withdrawal symptoms or medication-assisted treatment.
Example GIRP note for substance use (intensive outpatient group)
Fictional documentation example, not treatment guidance. Every detail is invented. Adapt it to the services you actually provided and your organization’s requirements.
Session details: Fictional adult client, 38, cocaine use disorder, moderate (F14.20; 5 of 11 DSM-5-TR criteria at intake). Intensive outpatient program (IOP), 3 hours a day, 3 days a week, week 3. This note covers his part in a 90-minute relapse-prevention group with 8 members; other members are not named in his record.
Goals: Treatment-plan goal: no cocaine use for 30 days, monitored through client report and random urine drug screens. Client’s goal for today, in his words: “get through payday Friday without calling anyone.”
Intervention: Clinician led the group on mapping high-risk situations (people, places, times, feelings and money) and taught urge surfing, with a 5-minute guided practice. Used motivational interviewing reflections and importance and confidence rulers with the client about his payday pattern. Reviewed that cocaine may contain fentanyl, the risk of using alone, and how to use naloxone; confirmed he still carries the naloxone kit given at intake.
Response: Client reports last cocaine use 16 days ago and no other drug use; alcohol: 2 beers once this week, which he linked to cravings. Urine drug screen collected by program staff on Monday was negative for cocaine (benzoylecgonine); consistent with his report. He mapped Friday payday, cash in his pocket and driving past his old dealer’s area as his highest-risk situation. Craving 6/10 when describing payday, 3/10 after urge surfing. Importance of stopping 9/10, confidence 6/10; he said confidence would rise “if I don’t have cash.” Participated actively and gave feedback to two members. Asked directly: denies thoughts of suicide, intent or plan; no past attempts or overdoses. Progress: client reports 16 days without cocaine use toward the 30-day goal. Monday’s negative urine screen is consistent with that report but does not establish continuous abstinence; payday remains the main barrier.
Plan: Client’s payday plan: arrange direct deposit, leave his bank card with his partner on Friday evening, take a different route home, and call his peer recovery coach if craving rises above 5/10. Continue IOP 3 days a week; random urine drug screen as scheduled by the program; individual session Thursday to review the payday plan. Keep carrying naloxone. 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 GIRP Notes for Substance Use Disorders
Start from the goal
Name the treatment-plan goal the session works on and the client’s session goal in their words, so the note shows why the service was needed.
Record each substance specifically
Write the substance, amount, how often, route and last use. “Polysubstance use” alone is not enough.
Write screen results with details
Record the test, the date, who collected it, the result, and whether it matches what the client reported.
Use neutral language
Write “negative for cocaine” and “returned to use,” not “clean” or “relapsed and failed.”
Document overdose risk
Record tolerance changes, using alone, fentanyl risk and naloxone access, and the education you gave.
Keep group members out
In a group note, record only this client’s participation. Do not name other members in this client’s record.
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Further Reading
- SAMHSA — Provides comprehensive resources and guidelines on substance use disorder treatment and documentation.
- DSM-5-TR — Offers standardized diagnostic criteria essential for accurate documentation of substance use disorders.
- APA Documentation Guidelines — Details best practices for clinical documentation, including note structuring relevant to GIRP notes.