Effective session notes are essential for quality therapy, continuity of care, and insurance compliance. Whether you use SOAP, DAP, BIRP, or GIRP format, this guide provides everything mental health professionals need to write clear, compliant, and clinically useful documentation. Learn what to include, how to choose the right format, and best practices for efficient note-taking.
Table of Contents
What Are Session Notes?
Session notes (also called progress notes or therapy notes) are clinical documentation that records what happened during a therapy session. They serve multiple purposes: ensuring continuity of care, demonstrating medical necessity for insurance, meeting legal and ethical requirements, and supporting treatment planning.
Key Purposes of Session Notes
- Document services provided and clinical rationale
- Track client progress toward treatment goals
- Support insurance billing and demonstrate medical necessity
- Enable continuity of care if another provider needs access
- Meet legal, ethical, and regulatory requirements
- Protect both client and therapist in legal situations
What to Document
A solid session note typically covers six key elements:
- Client presentation and behavior: Observable mood, affect, appearance
- What the client reported: Subjective symptoms, concerns, updates since last session
- Interventions used: Therapeutic techniques and approaches applied
- Client response: How the client reacted to interventions
- Clinical assessment: Your professional interpretation of progress
- Plan for next steps: Treatment adjustments, homework, next session focus
Progress Notes vs. Psychotherapy Notes
Understanding the distinction between progress notes and psychotherapy notes is critical for HIPAA compliance and protecting client privacy.
| Aspect | Progress Notes | Psychotherapy Notes |
|---|---|---|
| Part of Medical Record | Yes | No - kept separately |
| Content | Services provided, diagnosis, progress toward goals | Therapist's impressions, hypotheses, session details |
| Client Access | Clients can request access | Requires specific authorization |
| Sharing | Can be shared with other providers | Special HIPAA protections apply |
| Insurance | Used for billing and audits | Not used for billing |
Important HIPAA Distinction
Psychotherapy notes have special HIPAA protection and require specific written authorization from the client before release—even to insurance companies. Keep them physically or electronically separate from progress notes.
Session Note Formats Compared
There are several standard formats for therapy session notes. The best choice depends on your practice setting, personal preference, organizational requirements, and insurance requirements.
| Format | Structure | Best For |
|---|---|---|
| SOAP | Subjective, Objective, Assessment, Plan | Medical settings, multidisciplinary teams |
| DAP | Data, Assessment, Plan | Community mental health, private practice |
| BIRP | Behavior, Intervention, Response, Plan | Behavioral health, addiction counseling |
| GIRP | Goal, Intervention, Response, Plan | Goal-oriented therapy, insurance documentation |
SOAP Notes for Therapy
SOAP notes are perhaps the most widely used format in healthcare settings. They provide a standardized structure that clearly separates subjective reports from objective observations.
S - Subjective
The client's own words, statements, and reported feelings.
Example: "Client reports feeling 'overwhelmed at work' and experiencing difficulty sleeping for the past two weeks."
O - Objective
Observable behaviors, appearance, and measurable data.
Example: "Client appeared fatigued with dark circles under eyes. Speech was slower than baseline. PHQ-9 score: 14 (moderate)."
A - Assessment
Clinical interpretation combining subjective and objective information.
Example: "Client's symptoms are consistent with adjustment disorder with depressed mood. Work stressors appear to be primary trigger."
P - Plan
Next steps in treatment including interventions and homework.
Example: "Continue CBT weekly. Assigned sleep hygiene worksheet. Will assess for psychiatric referral if symptoms persist."
SOAP notes are often required by insurance companies and work well in medical or interdisciplinary settings where multiple providers need to access records.
DAP Notes Explained
DAP notes combine subjective and objective information into a single "Data" section, making them more streamlined than SOAP notes while maintaining clear structure.
D - Data
Both subjective reports and objective observations combined.
Example: "Client reports reduced anxiety since starting medication. Appeared more relaxed than previous session. Discussed coping strategies for upcoming job interview."
A - Assessment
Clinical interpretation of client's status and progress.
Example: "Client demonstrates improved coping skills and reduced anxiety symptoms. GAD-7 decreased from 15 to 9."
P - Plan
Next steps and treatment adjustments.
Example: "Continue biweekly sessions. Practice relaxation techniques before interview. Re-assess medication efficacy in 4 weeks."
DAP notes are particularly useful for clinicians who prefer a more narrative approach without detailed separation of subjective and objective data.
BIRP Notes Guide
BIRP notes focus on documenting specific behaviors and the interventions used to address them. This format is popular in community mental health and addiction counseling.
B - Behavior
The client's observable actions, words, and presentation.
Example: "Client arrived on time. Reported 3 days of sobriety. Spoke openly about triggers experienced this week."
I - Intervention
The therapeutic techniques and approaches you used.
Example: "Utilized motivational interviewing to explore ambivalence about recovery. Reviewed HALT (Hungry, Angry, Lonely, Tired) tool."
R - Response
How the client responded to interventions.
Example: "Client was receptive to discussion. Identified loneliness as primary trigger. Committed to attending AA meeting this week."
P - Plan
Next steps in treatment.
Example: "Continue weekly sessions. Client will call sponsor when experiencing loneliness. Follow up on AA attendance next session."
GIRP Notes for Goal-Oriented Therapy
GIRP notes put treatment goals front and center, making them ideal for solution-focused therapy and demonstrating progress for insurance documentation.
G - Goal
The treatment goal addressed in this session.
Example: "Goal: Reduce panic attack frequency from 5x/week to 1x/week within 8 weeks."
I - Intervention
Therapeutic techniques applied toward the goal.
Example: "Taught diaphragmatic breathing and grounding techniques. Practiced in-session exposure to anxiety-provoking scenario."
R - Response
Client's response and progress toward goal.
Example: "Client successfully used breathing technique to reduce anxiety from 8/10 to 4/10. Reports only 2 panic attacks this week (down from 5)."
P - Plan
Next steps to continue progress toward goal.
Example: "Practice breathing 3x daily. Begin interoceptive exposure next session. Goal on track for completion."
Essential Components for All Session Notes
Regardless of format, certain elements must be included in every session note for compliance and clinical utility:
Required Elements
- Service date
- Session duration (start/end time)
- Diagnosis/diagnoses
- Presenting symptoms/concerns
- CPT code for service type
- Interventions used
- Client response to treatment
- Progress toward treatment goals
- Plan for next steps
- Provider signature/credentials
HIPAA and Compliance
Mental health professionals must ensure session notes comply with legal, ethical, and regulatory standards. Requirements vary by country, state, and licensing board.
HIPAA Requirements (US)
- Ensure confidentiality and secure storage of records
- Keep psychotherapy notes separate from progress notes
- Clients have right to access progress notes (with limited exceptions)
- Use secure, encrypted systems for electronic records
Record Retention
Most professionals retain records for at least 5-7 years after the last session, or longer for minors (typically until age 21-25). Check your state's specific requirements and licensing board guidelines.
Insurance/CMS Requirements
- Notes must demonstrate medical necessity
- Include all required elements (date, duration, diagnosis, etc.)
- Document progress toward measurable goals
- CMS does not require a standard form, but essential elements must be present
Best Practices for Session Notes
Timing
Complete notes within 24 hours of the session, and no later than 72 hours. Prompt documentation ensures accuracy and compliance.
Length
Aim for 150-400 words per session. Include enough detail for another clinician to understand what happened, why it mattered, and what comes next.
Language
Use objective, clinical language: "Reports feeling...", "Demonstrates improved coping skills...", "Exhibits symptoms of...". Avoid subjective or judgmental terms.
Privacy
Exclude sensitive personal details not relevant to treatment. Remember that progress notes may be accessed by clients, other providers, or insurance companies.
Writing Tips
- Be specific and measurable when documenting progress
- Connect interventions to treatment goals
- Avoid excessive jargon or abbreviations
- Write as if another clinician will read the note
- Document what you did and why, not just what the client said
Frequently Asked Questions
What are session notes in therapy?
Session notes (progress notes) are clinical documentation recording what happened during a therapy session. They include client presentation, interventions used, client responses, clinical assessment, and treatment plan updates. They demonstrate medical necessity for insurance billing.
What is the difference between progress notes and psychotherapy notes?
Progress notes are part of the official medical record and document services, clinical status, and treatment progress. Psychotherapy notes are separate, private reflections with special HIPAA protection requiring specific authorization for release.
What is the best format for therapy session notes?
The best format depends on your setting. SOAP works well in medical settings, DAP is popular in community mental health, BIRP is preferred for behavioral health and addiction, and GIRP is ideal for goal-oriented therapy and insurance documentation.
How long should therapy session notes be?
Aim for 150-400 words per session. Include enough detail for another clinician to understand what happened, why it mattered, what interventions were used, how the client responded, and what comes next.
How soon should session notes be completed?
Documentation should ideally be completed within 24 hours and no later than 72 hours. Prompt documentation ensures accuracy and maintains compliance.
What must be included in therapy session notes for insurance?
For insurance, include: service date, session duration, diagnosis, presenting symptoms, objective findings, clinical assessment, interventions used, client response, progress toward goals, and plan for next steps. Notes must demonstrate medical necessity.
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