PIE Notes for Bipolar Disorder: Example and Template
Overview
This guide is part of our complete PIE notes hub — format structure, a full clinical example, and all 72 diagnosis-specific templates.
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Short answer: a PIE note for bipolar disorder records the Problem addressed in the session (for example, early warning signs of hypomania, a depressive episode, or medication adherence, in the client’s words and with measures such as sleep hours or a rating scale), the Intervention you used (mood charting, relapse prevention planning, interpersonal and social rhythm therapy, family-focused work, coordination with the prescriber), and your Evaluation of the client’s response, current risk and what happens next.
PIE comes from nursing documentation and keeps each note tied to one or more numbered problems. For bipolar disorder, the most useful details are changes from the client’s own baseline: sleep, energy, speech, spending, irritability, activity and mood, compared with the early warning signs in their relapse prevention plan. A counselor records what the client reports about medication and coordinates with the prescriber; medication decisions belong to the prescriber.
What to document in a bipolar disorder PIE note
| Section | What to document | Example wording |
|---|---|---|
| Problem | The problem addressed, linked to the treatment plan | “Problem 1: early warning signs of a depressive episode (relapse prevention plan, goal 1).” |
| Problem | Changes from baseline, with numbers | “Sleeping 10–11 hours (usually 7–8); stopped going to the gym; PHQ-9 14 (6 four weeks ago).” |
| Intervention | The specific technique or plan used | “Reviewed mood chart; behavioral activation (two scheduled activities a day); fixed wake time under IPSRT.” |
| Intervention | Coordination, with consent | “With the client’s written consent, informed the prescribing psychiatrist of the PHQ-9 change; review booked.” |
| Evaluation | Response to the intervention | “Client identified the pattern and agreed to the activity schedule; affect brighter at end of session.” |
| Evaluation | Risk and next steps | “Denied suicidal thoughts, plan or intent. Repeat PHQ-9 and review mood chart next week.” |
Watch for warning signs that need same-day help: several nights of little or no sleep with escalating energy, psychotic symptoms such as hallucinations or fixed false beliefs, risky behavior that could cause serious harm, or suicidal thoughts. Record who you contacted and when. For clients taking lithium, new vomiting, diarrhea, a coarse tremor, unsteadiness or confusion can indicate toxicity and need immediate medical assessment. For confusion, marked unsteadiness, seizures, collapse or rapidly worsening symptoms, call 911 or go to the nearest emergency department immediately. For other possible toxicity symptoms, contact the prescriber immediately for medical triage; if they cannot be reached, seek emergency medical assessment. Medication decisions belong to the treating medical clinician. If a client reports suicidal thoughts, assess and record current thoughts, plan, intent, preparatory behavior, past attempts, access to means, protective factors, your risk formulation and the safety plan. 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 PIE Notes for Bipolar Disorder
Problem
Define presenting problem(s), relevant background, current severity, and clinical context
When documenting the Problem section for bipolar disorder, clearly describe the patient's current mood state and any acute symptoms that are impacting their functioning. This section should capture the clinical presentation and symptom severity relevant to diagnosis and treatment planning.
- Document current mood episode (manic, hypomanic, depressive, mixed, or euthymic).
- Note presence and severity of psychotic features if applicable.
- Record any recent changes in sleep patterns or energy levels.
- Identify risk factors such as suicidal ideation or impulsivity.
- Describe functional impairments in social, occupational, or personal domains.
Intervention
Document therapeutic interventions, techniques, and clinical actions implemented during session
In the Intervention section for bipolar disorder, detail the specific clinical observations, therapeutic techniques, and treatment modalities utilized during the encounter. This includes medication adjustments, psychotherapy approaches, and safety planning.
- Record any medication changes including dosage adjustments or new prescriptions.
- Describe use of mood monitoring tools or symptom rating scales during session.
- Note application of psychoeducation focused on illness insight and relapse prevention.
- Document cognitive-behavioral or interpersonal therapy techniques used to address mood symptoms.
- Include any crisis intervention or safety planning strategies implemented.
Evaluation
Assess effectiveness of interventions, progress on problem resolution, and plan adjustments based on outcome
The Evaluation section should summarize the patient's response to treatment, progress toward goals, and any barriers encountered. Focus on measurable changes in mood symptoms, adherence, and overall stability.
- Assess improvement or worsening of mood symptoms since last visit.
- Evaluate patient's medication adherence and side effect profile.
- Review engagement with psychotherapy or support services.
- Identify any new or ongoing psychosocial stressors impacting stability.
- Determine need for treatment plan modification based on clinical response.
SOAP Notes for Bipolar Disorder
Alternative format for documenting bipolar disorder
DAP Notes for Bipolar Disorder
Alternative format for documenting bipolar disorder
BIRP Notes for Bipolar Disorder
Alternative format for documenting bipolar disorder
Progress Notes for Bipolar Disorder
Alternative format for documenting bipolar disorder
SIRP Notes for Bipolar Disorder
Alternative format for documenting bipolar disorder
GIRP Notes for Bipolar Disorder
Alternative format for documenting bipolar disorder
Example PIE Note for Bipolar Disorder
Fictional documentation example, not treatment guidance. Every detail is invented. Adapt it to the session you actually provided and your organization’s requirements.
Problem: Fictional adult client, session 14 of individual therapy for bipolar I disorder, most recent episode depressed, currently in partial remission (F31.75), 50 minutes by video. Takes lithium prescribed by their psychiatrist (client report). Treatment-plan goals: (1) notice early warning signs and act on them within 48 hours; (2) keep a regular sleep and wake time; (3) return to full-time hours at work. Problem 1 (early warning signs of depression): client reported sleeping 10–11 hours a night for 9 days (usually 7–8), skipping the gym, “everything feels heavy,” and calling in sick once. Mood chart ratings fell from 0 to −2 on a −3 to +3 scale. PHQ-9 14 (6 four weeks ago); item 9 scored 0. No signs of elevated mood reported or observed. Client denied missing lithium doses and reported no vomiting, diarrhea, new tremor or unsteadiness. Said, “I don’t want to wait until I can’t get out of bed.”
Intervention: Reviewed the mood chart and sleep log against the client’s relapse prevention plan. Behavioral activation: scheduled two activities a day for the next week (a 20-minute walk before work, a call with a friend), each rated for mastery and pleasure. Interpersonal and social rhythm therapy: set a fixed 7:00 a.m. wake time, with no naps longer than 30 minutes. With the client’s written consent, phoned the prescribing psychiatrist’s office and reported the change in sleep, mood and PHQ-9; a medication review was booked for Thursday. Asked directly about suicidal thoughts and reviewed the safety plan.
Evaluation: Client recognized the early warning signs (“this is how it went two winters ago”) and agreed to the activity schedule and wake time; affect constricted at the start, brighter when planning the walk. Progress on goal 1: client acted within 48 hours of noticing the signs (by booking this session early). Progress on goal 2 cannot yet be determined: the note records sleep duration but not consistency of sleep and wake times; review daily timing in the next sleep log. Goal 3 is at risk this week because the client missed work. Risk: denied suicidal thoughts, plan, intent or preparatory behavior, now and since the last session; one past suicide attempt 8 years ago during a depressive episode. Client reports no access to firearms and access to prescribed lithium at home. Reviewed medication storage and other available means; no additional access concerns reported. With the client’s agreement, partner will help secure medication while preserving access to prescribed doses; confirm the arrangement by phone tomorrow. Chronic suicide risk is elevated by bipolar disorder and the past attempt. Worsening depressive symptoms increase concern relative to baseline. Acute risk judged low today given the absence of current or recent suicidal ideation, plan, intent or preparation, active help-seeking, partner support and ability to use the safety plan; low risk does not mean no risk. Continued outpatient care is appropriate with prescriber coordination, means safety and close reassessment. Safety plan reviewed, including warning signs, coping steps and support contacts; reassess sooner if symptoms worsen or suicidal thoughts emerge. Client knows to call or text 988 if suicidal thoughts start, and to call 911 or go to the nearest emergency department in an emergency. Plan: weekly sessions; confirm medication storage tomorrow; repeat PHQ-9 and review the mood chart and activity log next session; continue to monitor for mixed or elevated mood.
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Tips for PIE Notes for Bipolar Disorder
1. Compare with the client’s baseline
Record sleep hours, energy, activity and mood against the client’s usual pattern and the early warning signs in their relapse prevention plan.
2. Use one scale consistently
Track the same measure over time, such as a daily mood chart, the PHQ-9 for depression or the Altman Self-Rating Mania Scale, and record the score and date.
3. Number the problem
Tie each PIE entry to a numbered problem and treatment-plan goal, so the evaluation shows progress on that goal.
4. Record medication as reported
Note what the client reports about medication and adherence and any coordination with the prescriber. Leave dosing and medication decisions to the prescriber.
5. Name the intervention
Write “behavioral activation,” “IPSRT sleep and wake schedule” or “relapse prevention plan review,” not just “supportive therapy.”
6. Document risk every time mood shifts
Record suicidal thoughts, plan and intent, risky behavior and psychotic symptoms whenever mood moves away from baseline, and who you contacted.
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Further Reading
- DSM-5-TR — Provides standardized diagnostic criteria for Bipolar Disorder essential for accurate problem identification in clinical documentation.
- APA Documentation Guidelines — Offers best practices for clinical documentation, including formats like PIE Notes, relevant to mental health professionals.
- NIMH (National Institute of Mental Health) — Contains authoritative information on bipolar disorder symptoms, treatment, and research to inform clinical interventions.