Progress Notes

Deep Dive

Progress Note formats

Narrative

G.I.R.P.

S.O.A.P.

D.A.P.

B.I.R.P.

+INFO

+INFO

+INFO

+INFO

+INFO

B.I.R.P. Example

Client Chart #: 111111 Date:11/7/2024 Time To: 1:02 PM Time From: 2:04 PM Duration: 1 hours, 4 units Therapist: Jessica Greil-Burkhart, LCSW Session/Service Type: Individual Therapy, in clinic, CPT code xxxxxx Behavior John presented with an anxious mood and congruent affect. He was alert and oriented x 4. He reported increased anxiety due to work demands and difficulty managing time. He rocked his legs up and down during session and had tremors in his hands. He stated, “I’ve been so overwhelmed, I don’t know how to manage it right now.” Intervention Therapist assessed for SI, HI, and self-harm behaviors. Therapist used CBT to explore thought patterns contributing to John’s anxiety. Therapist utilized cognitive restructuring techniques and 7 column thought log to help John challenge unhelpful thinking. Therapist led John through guided relaxation activity focused on managing stress in the moment. Therapist provided psychoeducation on stress and time management. Response John denied SI, HI, and self-harm behaviors. John actively engaged during session and identified unhelpful thoughts related to feeling like a failure as contributing to anxiety at work. John completed 7 column thought log and identified 3 helpful thoughts to counter anxiety provoking thoughts. John completed guided relaxation activity and identified feeling “relief, like a weight was lifted off me” upon completion. He identified how he could utilize relaxation activity while at work. John expressed an understanding of stress and time management. Plan Next session will continue utilizing CBT focused on anxiety reduction, introduce John to progressive muscle relxation for stress. John agreed to homework to utilize 7 column thought log throughout week.

Home Menu

D.A.P. Example

Client Chart #: 111111 Date:11/7/2024 Time To: 1:02 PM Time From: 2:04 PM Duration: 1 hours, 4 units Therapist: Jessica Greil-Burkhart, LCSW Session/Service Type: Individual Therapy, in clinic, CPT code xxxxxx Data John presented with an anxious mood and congruent affect. He was alert and oriented x 4. He reported increased anxiety due to work demands and difficulty managing time. He rocked his legs up and down during session and had tremors in his hands. He stated, “I’ve been so overwhelmed, I don’t know how to manage it right now.” Therapist assessed for risk behaviors and then utilized CBT to explore and challenge unhelpful thinking patterns related to anxiety. Therapist led John through guided relaxation activity focused on managing stress in the moment and provided psychoeducation on stress and time management. Assessment John denied SI, HI, and self-harm behaviors. John actively engaged during session and identified unhelpful thoughts related to feeling like a failure as contributing to anxiety at work. John appears to experience defeatist thinking often related to his work performance, with him identifying the need to be perfect and feeling like he “always messes up.” John completed 7 column thought log and identified 3 helpful thoughts to counter anxiety provoking thoughts. John completed guided relaxation activity and identified feeling “relief, like a weight was lifted off me” upon completion. He identified how he could utilize relaxation activity while at work. John expressed an understanding of stress and time management. Plan Next session will continue utilizing CBT focused on anxiety reduction, introduce John to progressive muscle relxation for stress. John agreed to homework to utilize 7 column thought log throughout week.

Home Menu

S.O.A.P. Example

Client Chart #: 111111 Date:11/7/2024 Time To: 1:02 PM Time From: 2:04 PM Duration: 1 hours, 4 units Therapist: Jessica Greil-Burkhart, LCSW Session/Service Type: Individual Therapy, in clinic, CPT code xxxxxx Subjective John reported anxiety over the past week stating, ‘I’ve been so overwhelmed, I don’t know how to manage it right now.” He identified work and time management concerns as stressor. He reported initial and middle insomnia, low energy, and poor appetite due to anxiety. Objective John presented with an anxious mood and congruent affect. He was alert and oriented x 4. He rocked his legs up and down during session and had tremors in his hands. John actively engaged throughout session. His thought process appeared logical with appropriate insight and judgment. His GAD-7 score at time of assessment was 19/21 indicating severe anxiety. Assessment John denied SI, HI, and self-harm behaviors. John actively engaged during session and identified unhelpful thoughts related to feeling like a failure as contributing to anxiety at work. John appears to experience defeatist thinking often related to his work performance, with him identifying the need to be perfect and feeling like he “always messes up.” John completed 7 column thought log and identified 3 helpful thoughts to counter anxiety provoking thoughts. John completed guided relaxation activity and identified feeling “relief, like a weight was lifted off me” upon completion. He identified how he could utilize relaxation activity while at work. John expressed an understanding of stress and time management. Plan Next session will continue utilizing CBT focused on anxiety reduction, introduce John to progressive muscle relxation for stress. John agreed to homework to utilize 7 column thought log throughout week.

Home Menu

G.I.R.P. Example

Client Chart #: 111111 Date:11/7/2024 Time To: 1:02 PM Time From: 2:04 PM Duration: 1 hours, 4 units Therapist: Jessica Greil-Burkhart, LCSW Session/Service Type: Individual Therapy, in clinic, CPT code xxxxxx Goal The goal of today’s session was focused on reducing anxiety related to work. John identified a desire to develop better time management skills, learn ways to manage stress in the moment while at work, and to reduce defeatist thinking about his capabilities as an employee. John presented with an anxious mood and congruent affect. He was alert and oriented x 4. He rocked his legs up and down during session and had tremors in his hands. John actively engaged throughout session. His thought process appeared logical with appropriate insight and judgment. Intervention Therapist assessed for SI, HI, and self-harm behaviors. Therapist used CBT to explore thought patterns contributing to John’s anxiety. Therapist utilized cognitive restructuring techniques and 7 column thought log to help John challenge unhelpful thinking. Therapist led John through guided relaxation activity focused on managing stress in the moment. Therapist provided psychoeducation on stress and time management. Response John denied SI, HI, and self-harm behaviors. John actively engaged during session and identified unhelpful thoughts related to feeling like a failure as contributing to anxiety at work. John completed 7 column thought log and identified 3 helpful thoughts to counter anxiety provoking thoughts. John completed guided relaxation activity and identified feeling “relief, like a weight was lifted off me” upon completion. He identified how he could utilize relaxation activity while at work. John expressed an understanding of stress and time management. Plan Next session will continue utilizing CBT focused on anxiety reduction, introduce John to progressive muscle relxation for stress. John agreed to homework to utilize 7 column thought log throughout week.

Home Menu

narrative/Summary Example

Client Chart #: 111111 Date:11/7/2024 Time To: 1:02 PM Time From: 2:04 PM Duration: 1 hours, 4 units Therapist: Jessica Greil-Burkhart, LCSW Session/Service Type: Individual Therapy, in clinic, CPT code xxxxxx John presented with an anxious mood and congruent affect. He was alert and oriented x 4. He reported increased anxiety due to work demands and difficulty managing time. He rocked his legs up and down during session and had tremors in his hands. He stated, “I’ve been so overwhelmed, I don’t know how to manage it right now.” John denied SI, HI, and self-harm behaviors. Therapist used CBT to explore thought patterns contributing to John’s anxiety with John identifying unhelpful thoughts related to feeling like a failure. John actively engaged when therapist utilized cognitive restructuring techniques, and a 7-column thought log. He identified 3 helpful thoughts to counter anxiety provoking thoughts. Therapist led John through guided relaxation activity focused on managing stress in the moment. John reported feeling “relief, like a weight was lifted off me” upon completion and identified how he could utilize relaxation activity while at work over the next week. John expressed an understanding of the psychoeducation on stress and time management provided by therapist. The plan for next session is to continue utilizing CBT focused on anxiety reductio and introduce John to progressive muscle relaxation for stress. John agreed to homework to utilize 7 column thought log throughout week.

Home Menu

Narrative/Summary

• Paragraph style progress note written as a cohesive, flowing summary
• Does not use labeled sections such as BIRP, SOAP, or DAP
• Integrates presenting concerns, interventions used, client response, and plan for next steps into one clinical narrative
• Structure is embedded in the writing rather than separated by headings
• Although it does not use headings, it still contains the same core components as other formats.

Click for example

S.O.A.P.

Subjective Observations

• Description of client's reported symptoms/functioning
• Reason for presenting/session
• Attitude/thoughts about progress

Objective Observations

• Therapist's observations of client
• Test results

Assessment

• Summary of symptoms, diagnosis
• Summary of session/interventions used
• How client is progressing in treatment/responding to treatment

Plan

• Plan to treat symptoms
• Plan for next session

Click for example

D.A.P.

Data

• Description of observations of clients
• Observations from social worker
• Report of symptoms on progress from client
• Reason for visit
• What happened (interventions used in session, client response to interventions)

Assessment

• Assessment of symptomsWhat interventions and techniques were used.
• Outcome of session and overall course of treatment
• How client is progressing toward goals
• Needed changes to treatment plan

Plan

• Assigned homework
• Interventions to use for next session

Click for example

B.I.R.P.

Behavior

• Description of overall behavior exhibited by client during session
• Appearance, demeanor, general observations of client's functioning/behavior
• Client's reports of functioning/behavior, progress since last session (can include quote)

Intervention

• Description of what the social worker did/intervention(s) used to help client work toward goals
• What interventions and techniques were used.
• Evidence-based treatment/techniques

Response

• Description of how the client responded/participated with the interventions

Plan

• Anticipated next steps to be taken with client/focus for next meeting Any changes to treatment plan

Click for example

G.I.R.P.

Goals

• Describe what the goals and objectives addressed in session were
• Progress toward goals
• How individual feels about goals
• Observations

Intervention

• Intervention/strategies used

Response

• Client's response to the interventions used
• Social Worker's observations and assessment of client's response to intervention

Plan

• Next steps/plans for next contact

Click for example