GuideUpdated October 1, 20263 min read

BIRP, DAP, SOAP and GIRP: a progress note format guide

The same 53-minute CBT session written four ways, with what each section must contain, when to pick each format, and the mistakes that fail audits in all of them.

For: Clinicians, supervisors, clinical documentation trainers

One session, four formats

Individual CBT session · 53 min · 90837

Fictional client "R.", 41, F41.1 Generalized anxiety disorder

Goal 2: Reduce worry-driven avoidance at work (Objective 2b: deliver 1 team update per week without calling in sick)

Behavior · Intervention · Response · Plan

Best for: Community mental health, Medicaid and SUD programs that want interventions and response called out explicitly.

Behavior: R. arrived on time, fidgeting, rapid speech. Reports calling in sick Monday to avoid presenting a team update. GAD-7 today 14 (moderate), down from 16 two weeks ago. Denies SI/HI.
Intervention: Cognitive restructuring (Objective 2b): identified catastrophic prediction ("I'll freeze and get fired"), examined evidence from three prior updates. Built a graded exposure hierarchy for speaking in meetings; rehearsed step 2 in session.
Response: R. generated two balanced alternatives and rated belief in the original thought down from 85% to 50%. Completed in-session rehearsal; SUDS peaked at 70, settled to 40.
Plan: Homework: attempt step 2 (one comment in Thursday meeting), log SUDS before and after. Continue weekly CBT; GAD-7 at next session. Progress toward Objective 2b: partial.

Format matters less than people think. Every progress note, in any format, has to show the same things: what you observed, what you did, how the client responded, how that relates to the treatment plan, and what happens next. Formats just decide where each piece goes.

What every format must contain

Date, start and stop time (or total time), modality and place of service
Who was present, and consent to record if ambient documentation was used
The treatment-plan goal or objective addressed
A named intervention — the modality and technique, not 'supportive counseling'
The client's response, ideally with a measure or observable behavior
Risk status when indicated (and always when risk was discussed)
Plan and rationale for continued care
Clinician signature, credentials and date — plus supervisor co-signature where required

Choosing a format

Format	Sections	Strength	Watch for
BIRP	Behavior, Intervention, Response, Plan	Makes interventions and response impossible to skip; favored by many Medicaid programs.	'Behavior' turning into a session summary instead of observations.
DAP	Data, Assessment, Plan	Concise; good for experienced clinicians writing narrative notes.	Interventions buried in Data; Assessment that restates Data.
SOAP	Subjective, Objective, Assessment, Plan	Readable by medical colleagues; natural home for MSE and scores.	Objective left thin; no named intervention anywhere.
GIRP	Goal, Intervention, Response, Plan	Puts the golden thread first — the goal leads the note.	Copying the goal text verbatim every session with no progress statement.
PIRP / SIRP	Problem or Situation, Intervention, Response, Plan	Variants used by some programs for problem-focused or crisis work.	Same as BIRP.

If your organization has a required format, use it. If not, pick the one that makes your most common audit finding hardest to commit. Programs that get cited for missing interventions do well with BIRP or GIRP; programs where notes are read by primary care do well with SOAP.

Section by section

Behavior / Data / Subjective + Objective

Record what the client said (briefly, with a quote when it captures something important) and what you observed: appearance, affect, speech, behavior, measure scores. Keep interpretation out of this section. 'Client was anxious' is an assessment; 'fidgeting, rapid speech, GAD-7 14' is data.

Intervention

Name the modality and the specific technique, and link it to the objective. 'Cognitive restructuring of catastrophic prediction (Objective 2b)' passes review. 'Processed feelings about work' does not, because it doesn't describe skilled treatment.

Response / Assessment

How did the client respond in session, and what does that mean for progress? A response is something that changed or didn't: a belief rating, a SUDS score, a skill demonstrated, a measure trend. The assessment ties it to the diagnosis and to medical necessity.

Plan

Next steps, homework, frequency, upcoming measures, referrals — and, for payers that ask, why care continues. 'Continue plan' is not a plan.

Mistakes that fail audits in every format

A note that fails90837 · no times recorded

Behavior: Client presented as anxious.
Intervention: Provided supportive therapy.
Response: Client was receptive.
Plan: Continue plan.

Fails: No time to support 90837, no goal, no named intervention, no measurable response, and text that could be pasted into any client's chart — the definition of a cloned note.

No time documentation for timed codes — the most common finding in federal psychotherapy audits.
Identical text across sessions or across group members.
No link to the treatment plan, or a link to a plan that has expired.
Risk mentioned in the session but absent from the note.
Late signatures beyond your state or payer's window, or missing supervisor co-signature.

Group notes

Group notes need a shared section (topic, duration, number of members, facilitator interventions) and an individualized section for each member: their participation, response and progress toward their own goals. Write each member's section as if the shared section didn't exist. If two members' sections are interchangeable, an auditor will treat them as cloned.

Sources

01CMS Program Integrity Manual, Ch. 3 §3.3.2.4 (signatures) and Ch. 6 (cloned documentation)
02HHS OIG, national audit of Medicare psychotherapy services (May 2023) (opens in a new tab)

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