GIRP Notes for Substance Use Disorder: Template + Examples (2026)
Overview
The GIRP Notes format provides an excellent structure for documenting Substance Use Disorder because it separates subjective experience from objective observations while emphasizing clinical assessment and planning. When working with clients presenting with Substance Use Disorder, the key is to document how the specific symptoms, behavioral patterns, and treatment responses are understood through the lens of this particular format.
Each section of the GIRP Notes note should serve a specific purpose when documenting Substance Use Disorder. Rather than generic descriptions, each section should contain clinical information that directly relates to the diagnostic criteria, treatment indicators, and progress measures relevant to Substance Use Disorder. This requires understanding both how the format works and what aspects of Substance Use Disorder are most important to capture for insurance justification, treatment planning, and clinical decision-making.
Documentation quality matters significantly when treating Substance Use Disorder. Insurance companies need to see clear evidence of medical necessity, meaningful progress on treatment goals, and appropriate use of evidence-based interventions. The GIRP Notes structure, when properly applied to Substance Use Disorder, communicates this clinical picture clearly and compliantly.
How to Document GIRP Notes for Substance Use Disorder
Goals
Document current treatment goals, client's goals for this session, and progress toward established objectives
When documenting Goals for substance use disorder, clearly define the client’s short- and long-term recovery objectives that address abstinence, harm reduction, and improvement in psychosocial functioning. Goals should be specific, measurable, and tailored to the individual’s stage of change and substance use patterns.
- Establish client’s primary substance use reduction or abstinence target.
- Set goals related to improving coping skills to manage cravings and triggers.
- Include objectives for restoring or enhancing social and occupational functioning.
- Define goals for addressing co-occurring mental health symptoms or medical issues.
- Incorporate milestones for engagement in support systems (e.g., 12-step groups or peer support).
Intervention
Record specific interventions applied to address identified goals and advance treatment
In the Intervention section for substance use disorder, document the specific therapeutic techniques, clinical observations, and modalities utilized during the session to address substance use behaviors and underlying psychosocial factors.
- Apply motivational interviewing techniques to assess readiness for change and enhance motivation.
- Use cognitive-behavioral strategies to identify and challenge substance-related thought patterns.
- Administer relapse prevention planning and teach coping mechanisms for high-risk situations.
- Conduct psychoeducation about the physiological and psychological effects of substances used.
- Observe and note client’s affect, engagement, and verbal/nonverbal cues related to substance use topics.
Response
Note the client's response to goal-focused work, progress indicators, and barriers to goal achievement
Document the client’s clinical response to interventions for substance use disorder, including changes in insight, motivation, behavior, and symptomatology, as well as any new diagnostic considerations or barriers to progress.
- Evaluate client’s expressed motivation and readiness to change substance use behaviors.
- Note observable changes in client’s coping skills or reduction in substance use cravings.
- Assess client’s insight into the relationship between substance use and life consequences.
- Identify any emerging mental health symptoms or changes in co-occurring disorder status.
- Record client’s verbal and nonverbal reactions to therapeutic interventions and feedback.
Plan
Specify action steps, revised goals if needed, and timeline for goal achievement
The Plan section for substance use disorder should outline the next steps in treatment, including referrals, homework assignments, treatment adjustments, and scheduling to support continued recovery and address identified risks or needs.
- Schedule follow-up sessions focusing on relapse prevention and coping skill reinforcement.
- Refer client to specialized substance use programs, support groups, or medical evaluation as needed.
- Assign homework such as journaling triggers, practicing coping strategies, or attendance at support meetings.
- Modify treatment goals or interventions based on current progress and client feedback.
- Plan for coordination with family members or other healthcare providers to support recovery.
SOAP Notes for Substance Use Disorder
Alternative format for documenting substance use disorder
DAP Notes for Substance Use Disorder
Alternative format for documenting substance use disorder
BIRP Notes for Substance Use Disorder
Alternative format for documenting substance use disorder
Progress Notes for Substance Use Disorder
Alternative format for documenting substance use disorder
SIRP Notes for Substance Use Disorder
Alternative format for documenting substance use disorder
PIE Notes for Substance Use Disorder
Alternative format for documenting substance use disorder
Tips for GIRP Notes for Substance Use Disorder
Connect to Diagnostic Criteria
Always link your observations and interventions back to the specific diagnostic criteria for Substance Use Disorder. If you're documenting generalized anxiety disorder, reference the specific DSM-5 criteria. If you're documenting major depressive disorder, show evidence of the required number of depressive symptoms. This demonstrates clear clinical reasoning and justifies continued treatment.
Use Quantifiable Measurements
Don't simply write "Substance Use Disorder improving." Instead, use rating scales (0-10 severity scales, PHQ-9 scores, GAD-7 scores, etc.) to show concrete progress. Document specific behavioral changes: "Client reported anxiety decreased from 8/10 to 6/10 when discussing social situations," or "Depressive symptoms reduced by 3 points on PHQ-9."
Document Functional Impact
Show how Substance Use Disorder affects the client's daily functioning. Insurance requires evidence of functional impairment to justify treatment. Document specific impacts: "Unable to attend work meetings due to anxiety," or "Staying in bed until 2 PM due to depressed mood." Then show how treatment addresses these functional limitations.
Track Intervention Specificity
Rather than vague interventions, be specific about what you did and why. For Substance Use Disorder, document: "Taught progressive muscle relaxation for anxiety management," or "Assigned behavioral activation with goal to schedule one pleasant activity daily." Show how each intervention targets the specific symptoms of Substance Use Disorder.
Demonstrate Treatment Progress
Connect each session to overall treatment goals for Substance Use Disorder. Show how this session moved the client forward. Document barriers encountered and your response: "Client engaged in avoidance despite exposure assignment. Explored ambivalence about facing feared situations. Adjusted timeline."
Note Comorbidities
Clients with Substance Use Disorder often have other conditions. Document any comorbid diagnoses and how they interact. For example: "Client's Substance Use Disorder is complicated by concurrent depression, which reduces treatment response. Added behavioral activation to address depressive symptoms alongside anxiety-specific exposure work."
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Further Reading
- SAMHSA — Provides comprehensive resources and guidelines specific to Substance Use Disorder treatment and documentation.
- DSM-5-TR — Offers diagnostic criteria and clinical information essential for accurate identification and documentation of Substance Use Disorders.
- APA Documentation Guidelines — Details best practices for clinical documentation, including note formats like GIRP, relevant to mental health professionals.