Clinical Notes

BIRP Notes

A BIRP note documents therapy sessions in four sections: Behaviour, Intervention, Response, and Plan — focusing on what happened and how the client responded.

Note Types

DAP Notes

A DAP note is a streamlined clinical documentation format with three sections: Data, Assessment, and Plan — combining subjective and objective information.

Note Types

GAD-7: Anxiety Screening

The GAD-7 (Generalised Anxiety Disorder-7) is a seven-item self-report measure used to screen for anxiety severity, scored 0-21, commonly paired with the PHQ-9.

Assessments

GIRP Notes

A GIRP note is a goal-oriented documentation format with four sections: Goals, Intervention, Response, and Plan — tying every session to treatment objectives.

Note Types

Mental Status Exam

A Mental Status Exam (MSE) is a structured assessment of a client's cognitive and emotional functioning at a specific point in time, covering appearance, mood, thought, and cognition.

Assessments

PHQ-9: Depression Screening

The PHQ-9 (Patient Health Questionnaire-9) is a nine-item self-report measure used to screen for depression severity, scored 0-27, widely used in routine outcome monitoring.

Assessments

Progress Notes

Progress notes are clinical records that document a client's treatment progress over time, including session summaries, interventions, and outcomes.

Note Types

Psychotherapy Notes

Psychotherapy notes are a therapist's private process notes about a client's session, granted special protection under HIPAA and stored separately from the clinical record.

Note Types

Risk Assessment and Safety Planning

Risk assessment is the clinical evaluation of a client's potential for self-harm, suicide, or harm to others, guiding safety planning and intervention decisions.

Assessments

SOAP Notes

A SOAP note is a structured method of clinical documentation that organises session information into four sections: Subjective, Objective, Assessment, and Plan.

Note Types

Termination Notes

A termination note is a clinical summary written at the end of treatment that documents the reason for ending therapy, progress made, and referrals provided.

Note Types