SIRP Notes for Major Depressive Disorder: Template + Examples (2026)
Overview
The SIRP Notes format provides an excellent structure for documenting Major Depressive Disorder because it separates subjective experience from objective observations while emphasizing clinical assessment and planning. When working with clients presenting with Major Depressive 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 SIRP Notes note should serve a specific purpose when documenting Major Depressive 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 Major Depressive Disorder. This requires understanding both how the format works and what aspects of Major Depressive Disorder are most important to capture for insurance justification, treatment planning, and clinical decision-making.
Documentation quality matters significantly when treating Major Depressive Disorder. Insurance companies need to see clear evidence of medical necessity, meaningful progress on treatment goals, and appropriate use of evidence-based interventions. The SIRP Notes structure, when properly applied to Major Depressive Disorder, communicates this clinical picture clearly and compliantly.
How to Document SIRP Notes for Major Depressive Disorder
Situation
Describe the presenting situation, precipitating events, current stressors, and context surrounding this session
When documenting the Situation section for major depressive disorder, clearly describe the current clinical presentation including mood, affect, and any recent changes in symptom severity or psychosocial stressors. This section should provide a concise snapshot of the patient's mental state and relevant context at the time of the encounter.
- Document patient's reported mood and affect, noting any signs of sadness, hopelessness, or irritability.
- Note presence or absence of suicidal ideation, intent, or plan since last visit.
- Record changes in sleep patterns, appetite, energy levels, or psychomotor activity.
- Identify recent psychosocial stressors or life events impacting depressive symptoms.
- Summarize any cognitive symptoms such as concentration difficulties or feelings of worthlessness.
Intervention
Document specific therapeutic interventions, techniques, and clinical actions taken during the session
In the Intervention section for major depressive disorder, detail the specific therapeutic techniques, clinical observations during the session, and any modalities applied to address depressive symptoms. Include adjustments to pharmacotherapy or psychotherapeutic strategies used during the encounter.
- Describe use of cognitive-behavioral techniques targeting negative thought patterns.
- Note administration or adjustment of antidepressant medications including dosage changes.
- Document engagement in motivational interviewing to enhance treatment adherence.
- Record observation of patient's affect, eye contact, and psychomotor behavior during session.
- Specify use of relaxation or mindfulness exercises introduced to reduce anxiety or rumination.
Response
Record the client's response to interventions, observable changes, and emotional/behavioral reactions
The Response section should capture the patient's clinical progress, reactions to interventions, and any emerging diagnostic considerations related to major depressive disorder. Focus on evaluating symptom changes, treatment adherence, and patient feedback.
- Assess patient's reported improvement or worsening of depressive symptoms since last visit.
- Evaluate adherence to prescribed medications or therapeutic homework assignments.
- Note any new or escalating suicidal ideation or safety concerns.
- Document patient's insight into illness and motivation for treatment.
- Consider differential diagnoses if symptom presentation has changed or atypical features emerge.
Plan
Outline next steps, follow-up care, and ongoing treatment strategy based on current situation and response
In the Plan section for major depressive disorder, outline the next steps in treatment including medication management, therapy goals, referrals, and scheduling. Specify any modifications based on current progress and plan for ongoing monitoring of risk and symptomatology.
- Adjust or continue antidepressant medication with rationale and monitoring parameters.
- Assign specific therapeutic homework targeting cognitive distortions or behavioral activation.
- Schedule follow-up session with timeline based on symptom severity and risk assessment.
- Refer to psychiatry, social work, or support groups as indicated for additional resources.
- Plan safety measures including crisis intervention strategies if suicidal ideation persists.
SOAP Notes for Major Depressive Disorder
Alternative format for documenting major depressive disorder
DAP Notes for Major Depressive Disorder
Alternative format for documenting major depressive disorder
BIRP Notes for Major Depressive Disorder
Alternative format for documenting major depressive disorder
Progress Notes for Major Depressive Disorder
Alternative format for documenting major depressive disorder
GIRP Notes for Major Depressive Disorder
Alternative format for documenting major depressive disorder
PIE Notes for Major Depressive Disorder
Alternative format for documenting major depressive disorder
Tips for SIRP Notes for Major Depressive Disorder
Connect to Diagnostic Criteria
Always link your observations and interventions back to the specific diagnostic criteria for Major Depressive 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 "Major Depressive 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 Major Depressive 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 Major Depressive 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 Major Depressive Disorder.
Demonstrate Treatment Progress
Connect each session to overall treatment goals for Major Depressive 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 Major Depressive Disorder often have other conditions. Document any comorbid diagnoses and how they interact. For example: "Client's Major Depressive 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
- DSM-5-TR — Provides the official diagnostic criteria for Major Depressive Disorder essential for accurate clinical documentation.
- APA Documentation Guidelines — Offers detailed guidance on clinical documentation practices relevant to mental health professionals using structured note formats.
- NIMH (National Institute of Mental Health) — Contains up-to-date research and information on Major Depressive Disorder to inform evidence-based clinical documentation.