SOAP. DAP. BIRP. DART. What do all these acronyms mean?? I’m here to tell you!

In this series, I’ll be reviewing different types of common progress notes, how to fill them out, and why they’re important.

Types of Progress Notes

Let’s start with simply putting those acronyms into words:

• SOAP = Subjective, Objective, Assessment, Plan

• DAP = Data/Describe, Assessment, Plan

• DART = Description, Assessment, Response, Treatment Implications/Plan

• BIRP = Behaviors, Intervention, Response, Plan

When it comes down to it, they all look pretty similar, don’t they? Their structure follows these basic sections:

1. Observations

2. Assessment

3. Responses

4. Plan

Why is there no universal progress note format?

If all these progress note formats are so similar, why use different formats at all? Why isn’t there just a universal progress note format?

The reason why there is no universal progress note format is that it would be impossible to capture all the different data needed for specific situations. What you need to record in a private practice setting can be quite different from what needs to be recorded in an inpatient hospital setting. In fact, even these basic progress note formats are often personalized even further to suit the clinician’s and/or clinic’s needs.

For example, in the community mental health agency where I worked, we primarily followed a SOAP format. However, we also needed to address the BIRP requirements of our local Medicaid office. So, I ended up creating a hybrid progress note that could address both needs.

Progress Note Examples

In this series I will be providing an example of each progress note type using the same fictional session between a therapist named Mary Brown and her adult client, Jane Smith. You’ll have the chance to see what the same data would look like across all the different note formats.

SOAP Progress Note Template

If you’d like to use the SOAP Progress note template you see here, you can purchase it for instant download, or as part of a package with all forms, all client file forms, and all progress notes.

DA(R)P Progress Note Template

If you’d like to use the DA(R)P Progress note template you see here, you can purchase it for instant download, or as part of a package with all forms, all client file forms, and all progress notes.

DART Progress Note Template

If you’d like to use the DART Progress note template you see here, you can purchase it for instant download, or as part of a package with all forms, all client file forms, and all progress notes.

BIRP Progress Note Template

If you’d like to use the BIRP Progress note template you see here, you can purchase it for instant download, or as part of a package with all forms, all client file forms, and all progress notes.

Series Conclusion

I hope this series on Types of Progress Notes was informative and helpful for you in your practice. If you have a favorite type of progress note, comment below to share with us what it is and why. If you feel that I’ve left something out, or think I should’ve included another progress note format, you’re welcome to send me a message anytime to let me know.

I do hope you’ll consider following me as we continue together exploring the nuts & bolts of psychotherapy paperwork, some tips and tricks of the trade, and the ethics behind it all

What should be on every form

It is my belief that you should create and fill out your paperwork as if every piece of paper could end up used as evidence in court. I know that sounds extreme but it’s the best way to cover your butt and make sure that your files are legible to anyone who might see them, whether that’s another clinician, SSDI, or even, yes, the court. With that in mind, what should be on every form to make sure it meets this standard?

One way to think about it is that with every piece of paperwork you should be able to easily figure out the following things:

• ·The purpose of the document,

• Who the client is,

• When the form was written, and

• Who wrote it.

That’s not much if you think about it. All that usually entails is a form title, space for a client’s name, a dated signature or filled date, and your name with full license and title information. All the forms available to download on my site meet this criterion so you’ll never have to worry about whether you’re hitting this standard.

Now, what should be in every form is a different question altogether! Hopefully, I’ll be able to answer some of those questions as we continue with these blog posts.

Here are a few things to consider when setting up your e-mail signature.

Full Credential and License Information

In California at least, it is required by law that any time a clinician interacts with the general public, including a client, they must include their full name, credentials, and license number. If you are still in training and are under the supervision of a licensed clinician, you must also indicate that as well as include your supervisor’s information. See the next section for more information about that.

Here is an example of a proper and full signature name of a licensed clinician:

Mary Brown, LMFT (MFC12345)

Licensed Marriage & Family Therapist

As a licensed individual, you are not required to spell out your title’s acronym but ethically I think it’s a good practice. After all, most clients and the public have no idea what our acronyms mean.

Clinicians in training

Still speaking from California, one important thing to note is that if you are not yet licensed, you can’t just stick to acronyms. While you can include an acronym for your credentials, it must also be spelled out. For example, if you are an Associate Marriage and Family Therapist, you may use the acronym AMFT but it must also be spelled out. Here is an example of a proper and full signature for a clinician in training:

John Doe, AMFT (12345)

Associate Marriage and Family Therapist

Under the supervision of

Mary Brown, LMFT (MFC 12345)

Licensed Marriage and Family Therapist

This is because few people understand the difference between AMFT and LMFT and to avoid even the whisper of misrepresentation of your licensing status, you must make your title and credentials clear.

Working in a clinic or other organization

If you are a clinician working in a clinic or other organization, you must also always provide the clinic or organization’s name along with your own. Here is an example of a licensed individual working at a nonprofit clinic:

Mary Brown, LMFT (MFC 12345)

Licensed Marriage and Family Therapist

Nonprofit Clinic Name

Confidentiality Notice

You’ve probably seen those confidentiality notices at the end of a clinician’s email, but are those really necessary? Well, they’re not required by federal law per se (yet) but they are an excellent response to HIPAA’s requirement that a clinician take reasonable steps to help safeguard a client’s PHI (Personal Health Information). The HHS also provides the following recommendations:

“certain precautions may need to be taken when using e-mail to avoid unintentional disclosures, such as checking the e-mail address for accuracy before sending, or sending an e-mail alert to the patient for address confirmation prior to sending the message. Further, while the Privacy Rule does not prohibit the use of unencrypted e-mail for treatment-related communications between health care providers and patients, other safeguards should be applied to reasonably protect privacy, such as limiting the amount or type of information disclosed through the unencrypted e-mail.”

Please note that while including a confidentiality notice helps you remain HIPAA compliant, it’s presence alone doesn’t mean your entire practice is HIPAA compliant. That’s a post for another day.

Pronouns

This is not a legal requirement by any means, but as the world progresses, it is turning into good practice. By providing your pronouns first, you are not pressuring trans and nonbinary people to share their pronouns if they are uncomfortable doing so. After all, many trans and nonbinary are not out in their day-to-day life due to the potential for discrimination and violence. Instead, it offers the opportunity for them to share in return if they wish to do so. It’s important that all clients feel welcome, and this is just one small step you can take to do that.

Here is an example of an email signature including pronouns:

Mary Smith, LMFT (MFC 13245)

Licensed Marriage and Family Therapist

Pronouns: she/her

It’s really that simple.

If you’d like to learn more about pronouns and why they’re important, check out this great article by Includr.

You’ve just received a request for your client’s files. What do you do?

Well, that depends on who is asking and why.

The number one thing to keep in your mind at all times is your duty to protect a client’s confidentiality. Regardless of who is asking, your number one priority is to safekeep your client’s records unless given express permission to do otherwise.

The below examples are theoretical and if you are concerned or have any questions regarding the legal nature of any file request, please contact a legal professional.

As an example, let’s say a client is applying for Social Security Disability Insurance (SSDI) based on a mental health condition. In this case, the client should be informed that there is a strong possibility that the Social Security Administration (SSA) will request the client’s records. In which case, the client should sign a Release of Information (ROI) form to indicate their consent to share their files with the SSA. This may include a summary of treatment, diagnosis, and dates of sessions attended or it can include the entire medical record. It can even include both. It is up to your best clinical judgement to decide the balance between protecting your client’s confidentiality and what would be the most beneficial to their case. Most often you will be sending these records to the SSA directly. However, always keep in the back of your mind that there is possibility your client will see what you send.

Now let’s cover court subpoenas.

When first presented with a court subpoena for a client’s records, make sure to scrutinize it’s validity and refresh your knowledge of state and federal guidelines for your clinical discipline. If you have any doubts about the validity of the subpoena or questions about how to respond to it, seek legal counsel immediately. This includes if the subpoena is from out of state as they may not be sufficient to compel a testimony from you.

If you have determined that the subpoena is valid, and you have not been given consent by the client to release information, neither confirm that you are working with a client nor provide their medical records. However, don’t completely ignore the subpoena either. Simply reply with a statement indicating that you are unable to comply nor indicate whether someone is a client or not. Do not try to avoid being served. It’s unprofessional and unlikely to work anyway.

If the client is unaware that a subpoena has been issued, it is very important that you speak with the client about your legal responsibilities and their rights as a client to confidentiality. Describe in detail the process you will go through to protect a client’s confidentiality and at what point you will be legally forced to relinquish it.

You should also discuss with your client any information in their medical files that could be potentially clinically or legally damaging to them in court. If the client still insists on releasing their medical records, make sure to note in their file your concerns and seek additional consultation if necessary.

If a client does agree to allow you to share their medical records, and you do not have concerns about any potential negative clinical or legal repercussions, provide only the minimum information requested or needed that will satisfy the subpoena. This can include a treatment summary rather than the entire medical record if it would satisfy all parties involved.

If you’re releasing raw test data, be aware of copyright laws and your agreements with the publishers of such forms as well as state and federal laws. Consult with a lawyer if you have any questions or concerns about a conflict of interest between the copyrighted tests and a subpoena.

Lastly, remember that process (or “psychotherapy”) notes are not part of the medical file and should not be included in any file requests. In fact, they should always be kept separate from the medical file entirely.

The Zur Institute has a great article that goes into more detail on responding to court subpoenas and has gathered legal information from several sources to assist in your decision making.

What to include

As for what to include when providing a client’s records, it again depends on who is asking. If it’s the courts, follow the guidelines above.

For anyone else, there are a couple of guidelines: one legal and the other ethical.

Legally, you may only release information about a client that they consent to. Your ROI should have several options for what kind of information is to be released so that the client can tailor what they are willing to share. This can include all files, only a treatment summary, a list of session dates attended, medical conditions, etc.

Ethically, if a client is requesting a copy of their own files for personal use, it is up to the therapist to use their best clinical judgement to decide what and how to present that information to the client. Again, this depends a bit on the nature of the request.

Most often a file request comes from a client because they wish to transfer information to a new therapist or psychiatrist. In this situation, it is common for the therapist to offer to send either a treatment summary or the files directly to the other mental health practitioner.

If the client wants the files simply because they’re curious, it is usually best to first discuss the request with the client. There should be an in-depth discussion regarding the client’s interest in the files, their goals in seeing them, and what options are available to them. If the client still wishes to see their files, it is usually best to offer the client a summary of treatment instead of direct access to the files. If the client insists on seeing the files themselves, it is recommended that the clinician sit with the client and review them together so that the therapist can clarify any confusion and answer any questions the client may have.

Documentation

And, of course, throughout this process document everything! You’ll want a clear paper trail showing that you’ve taken into consideration your legal and ethical duties to the client while also respecting relevant state and federal laws.

When writing progress notes, the line between subjective and objective observations can be a bit blurred. Let’s break them down together.

Dictionary definitions

In the dictionary the terms are defined as:

Subjective: relating to properties or specific conditions of the mind as distinguished from general or universal experience.

Objective: not influenced by personal feelings, interpretations, or prejudice; based on facts; unbiased.

Progress note implications

How does this translate to a progress note? Partly that depends on the type of progress note.

For instance, as I discussed in my blog post on DART notes, the subjective experience is focused more on the therapist than the client. However, most progress note formats focus on the subjective experience of the client. For that reason, I’ll focus on the term subjective as it relates to the client.

Subjective: relating to the specific experience of the client as distinguished from general, universal (objective) experience

Objective: the therapist’s observations of the client and their presenting issues without including their own feelings or interpretations

Subjective Experiences

Since the subjective section of a progress note (usually) focuses on a client’s direct experience rather than our interpretation of it, it is often suggested that a direct quote about the presenting problem be used in this section of the note. For some clinicians, that’s where the subjective section ends. However, it can also include a brief description of the client’s subjective experience of the content session and/or their stated experiences of interventions used during session.

Objective Experiences

I’d first like to state that, of course, no one can truly be objective. That being said, the objective section of the progress note is intended to include information such as mental status exam (MSE) observations, observed responses to interventions, and factual information such as a brief description of session content without editorialization.

It’s important to remember that the SOAP progress note format was originally created for the medical field and so this is where the objective medical data, such as heart rate and blood pressure, was recorded. Therefore, translating it into a therapeutic narrative can be a bit more complex. That is one of the reasons that new progress note formats, such as DAP and BIRP, were created to adjust to this difference.

Over the next two months we’ll be going over what makes an excellent Treatment Plan. We’ll break down the process of how to turn Goals into SMART Objectives, and in turn Objectives into Steps and Benchmarks.

We’ll also look at how to update your Treatment Plan as well as discuss best practices for how often a Treatment Plan should be updated.

But before we do all that, let’s talk a little bit about what a Treatment Plan actually is.

What is a Treatment Plan?

A helpful way to think about Treatment Plans is to imagine them as signposts along the road of your therapeutic journey. Sometimes along that journey you discover that you’ll miss a signpost and so must find a new one to aim for. Or perhaps you passed that signpost a long time ago and it’s time to look for the next. These signposts are your goals, and they should be considered only guides, not set in stone.

A Treatment Plan serves many purposes but the most important of which is that it provides clarity of direction in your treatment of a client. Even if your goal is maintenance and not necessarily improvement, having that focus clear in your mind and regularly refreshed can bring a clear intent to your sessions. This is especially important with long-term clients when goals can begin to get lost amidst the weeds of session content as time goes on.

Another way to look at a Treatment Plan, and a whole client’s medical record, really, is that it’s a story of the client’s therapeutic journey. A thread should be visible from Intake to Termination. In that way, each progress note should strive to remain attached to the Treatment Plan and the Treatment Plan in return attached to what is happening in sessions. In fact, just as you record overall progress on the Treatment Plan itself, I would recommend reflecting on the progress of each Treatment Plan goal in each session’s progress note.

As you can see, each Objective is tailored toward reaching the Goal. The question to ask yourself when creating your Objectives is, “What are three things a client should be able to successfully do to meet the Goal?”

Limiting Objectives

You may have noticed that I keep referring to specifically three Objectives per Goal. That’s because any more than that and both you and the client can end up overwhelmed. Those excess Objectives then become unattainable, meaning they are no longer SMART. Again, we’ll talk more about SMART Objectives next week.

Let’s go over each section of a SMART Objective and come up with some examples.

Specific

What does it mean to make an Objective specific? It can be tempting to make a vaguer objective, such as “reduce anxiety” which is not very specific at all. Instead, ask yourself what does reduced anxiety actually look like. A more specific Objective would be something along the lines of “reduce panic attacks.”

The more overarching statement of “reduce anxiety” is better suited for a Treatment Plan Goal – the overall direction of treatment which we discussed last week.

Measurable

Let’s take the above specific Objective and make it measurable. You want to reduce the client’s panic attacks but by how much? Are you aiming for one less panic attack a week? What measure of success works best for your client and this Objective? Avoid using vague measurements, such as “fewer panic attacks” or “less anxiety resulting in panic attacks” because neither of those allow you to measure success and create specific Benchmarks. (We’ll discuss what Benchmarks are later in this series.) Come up with a specifically measurable Objective that anyone would be able to decipher.

Attainable

The Objective should be within the client’s control. For instance, if the panic attacks are a side effect of a medication, reducing them may not be an attainable Objective. (Hopefully, there aren’t any medications with panic attacks as a side effect! This is simply for the sake of the example.)

Realistic/Relative

While Objectives should not be considered set in stone, you should aim to make them realistically attainable. For instance, it may be unreasonable to expect a client’s panic attacks to resolve completely in 3 months. Instead, focus on what seems realistic for the client and their Objectives.

This letter of the acronym is also sometimes referred to as relative, as in the Objectives should make sense in terms of your overall Goal. In our example, reducing panic attacks would absolutely be relative to our overall Goal of reducing anxiety.

Time-Limited

Don’t leave your Objectives open-ended. Just as a signpost on a journey marks your progress, having an Objective end date allows you and your client to break down your Objectives into manageable chunks that can be measured and adjusted as treatment continues. It can be easy to get lost with an open-ended Objective, never quite sure if it’s truly attainable or needs modification.

Putting it all together

Having reviewed what a SMART Objective is, let’s put one together using the above examples.

Your overall Goal would be to reduce anxiety. One of your Objectives to meet that Goal would be to reduce panic attacks by one a week by (date 3 months from now). As you can see, the goal is specifically targeting panic attacks, measuring the reduction of panic attacks, is likely attainable and is certainly realistic and relative to the objective, within the timeline set.

Creating Benchmarks form SMART Objectives

Next week we’ll focus on how to turn Objectives into Benchmarks. In the meantime, if you’d like some assistance creating your own SMART Objectives, set up a consultation with me and we can create some together specifically for your clients.

Now that we know what Goals and Objectives are, where and how do we translate them into action?

Just as we considered what Objectives would be needed to meet a Goal, it is time to consider what Steps or Benchmarks would need to be taken to meet an Objective. I tend to use both Steps and Benchmarks interchangeably but really a Benchmark is the end result of a Step taken to meet an Objective.

Example

In my previous posts, we created a SMART Objective that stated a client would be able to reduce the number of panic attacks per week by one within three months of the goal creation date. Here is an example of some Steps that could be taken to meet that Goal:

1. Be able to identify and name panic attack triggers

2. Remain present to surroundings during panic attack

3. Implement self-care plan after panic attack

Format of Steps

The Steps for each Objective should be placed directly below that Objective. This is where you can transform them into Benchmarks. With each step, identify a date or specific and measurable sign that indicates progress toward achieving that step.

This can look something like:

Objective #1: Reduce the number of panic attacks per week by one within three months Due 3 months

Benchmark

1. Be able to identify and name panic attack triggers

2. Remain present to surroundings during panic attack

3. Implement self-care plan after panic attack

Remember to keep your Benchmarks specific as well, so that it is clear to anyone who reads it whether it has been met or not upon reassessment of the Treatment Plan.

Documenting Progress Status

As you regularly review your Treatment Plan, reflect on the Steps you listed. This will help you determine whether your Objective needs to be adjusted. Remember, not meeting a Benchmark does not mean you or the client failed! It simply means that a different Benchmark is needed. During this progress review is the time to make adjustments to your treatment signposts.

Documenting Progress in Progress Notes

As stated in a previous post, it is a good idea to track the smaller progress steps toward the Benchmarks in your progress notes. This helps keep the treatment record connected and focused. Here are some examples of possible progress indicators that you can use in your progress notes:

• Progressing: there is movement toward the Objective

• Variable: there is a mixture of both movement toward Objective and some movement away

• Regressed: there is movement away from the Objective

• Maintained: this is typically used for maintenance Objectives (such as ongoing harm reduction)

• Not Addressed: content related to the treatment Objective was not addressed in this session

• Resolved: the client has successfully met this Objective

Do this for each Objective and by the time it comes to review your Treatment Plan, it should be easy to go back through your progress notes and have a sense of where your client ended up in relation to their Benchmarks.

You’ll notice that this particular template does not give space specifically for Benchmarks, though you could just write them below your stated Objective. That’s because though they are incredibly useful, if you have a straight-forward SMART Objective, you may not need them. Though this template does not have the Benchmarks section, the other Treatment Plans available for purchase do include that space.

You may have heard of Treatment Planners. There are certainly many great ones out there. The most extensive and popular series is from Wiley Publishers called “Practice Planners” (https://amzn.to/3pl8ZyD) – a series of 40 different treatment planner books that range from age group to specific clinical presentations.

The most basic Treatment Planners being:

• The Complete Adult Psychotherapy Treatment Planner (https://amzn.to/3JeJNlc) *

• The Adolescent Psychotherapy Treatment Planner (https://amzn.to/30QVdKK) *

• The Child Psychotherapy Treatment Planner (https://amzn.to/3sqhVEP) *

These types of Treatment Planners are fantastic tools! I only have two cautions about them.

Know what you’re saying

These Treatment Planners provide a wealth of details on what to include in your Treatment Plan from a wide range of theoretical backgrounds. As I’ve mentioned before (paperworktherapy.com/blog/types-of-progress-notes-birp), many therapists have difficulty explaining what it is that they’re actually doing in sessions. These Planners can provide much of that language. Just make sure you fully understand what you’re saying if you choose to utilize their plans. You should be able to justify your Treatment Plan using your own words, not just those of the Planner.

Make it fit

Just because something sounds good on paper, doesn’t necessarily mean it fits your approach or a client’s needs. Don’t just copy and paste from the Treatment Planner, make it your own. Personalize each part of your Treatment Plan to make it the right fit for what you’re hoping to accomplish. And, of course, there are so many Goals, Objectives, Benchmarks, and Interventions that aren’t listed in these Planners that are available to you. Don’t get stuck thinking that you can only choose what’s on the page in front of you.

Treatment Plan Series Conclusion

And with this post, the series on Treatment Plans comes to a close. Though I’m sure that we’ll be revisiting aspects of the Treatment Plan in future posts. In the meantime, if you’d like to talk more in-depth about your Treatment Plans, set up a consultation with me. I’d love to work with you.

* note: I have an Amazon Affiliate account, which means I get a very small commission (1-10% of the product cost) if you choose to buy any of the products listed above through the links I provided.

We all know the importance of doing an initial intake assessment, but how many of us continue to reassess throughout our treatment with clients? What is a reassessment and what purpose does it serve?

The what’s and why’s

A reassessment is essentially a regular check-in with your client regarding any information that needs to be updated since their initial intake or previous reassessment. It can be something as simple as a shorter version of your intake form or you can make it a completely different form with its own relevant questions.

For those of you familiar with the Gottman's work, you know how important it is for couples to update their “love maps” – essentially the information they think they know about each other. The reason for this is because that information changes over time. To solidify and continue our connections, it is important that we check in regularly. The same is true for our relationships to our clients.

It can be easy to assume that our clients will tell us of changes in their life or update us on all of their current life circumstances. However, therapists are sometimes surprised to discover that in fact an important nugget of information went unnoticed because the client didn’t think it important or relevant to bring up in sessions.

While these reassessments can sometimes be done on your own as the therapist, I would strongly encourage you to go over each of the questions with your clients in order to trigger any thoughts or situations they had not thought (or avoided) to bring into session.

Creating a Reassessment

The simplest way to create a reassessment form is to take your intake form and change the questions to, “since our intake (or last reassessment) has X changed for you?” of “do you have any updates about X since the last time we checked in about it?”

Another approach to reassessment includes creating a new batch of questions that are relevant to your treatment. For instance, questions inquiring about the therapeutic relationship or treatment goals can be a focus of your reassessment. These kinds of questions can also be powerful tools in your ongoing treatment and clinical relationship.

Reassessment Frequency

I recommend that a reassessment be conducted every 6 months to 1 year after their first intake session and that reassessments continue on that schedule for as long as treatment continues. I’ve personally found that waiting an entire year can leave the client forgetting information because of how long ago it happened. I’ve found that every 6 months is ideal for capturing the most up to date and accurate information.

Reassessment Form

If you’d like to get started with a pre-made reassessment form, check out the one I have for sale. They are based on the Intake forms also available in my shop.