Questions clinicians ask about SOAP, DAP, BIRP and GIRP notes
These are the questions clinicians and students ask when the session is over and the note is still open.
Each answer gives you one rule or one phrase from the guides. Follow your agency's template and policy.
What is the difference between SOAP, DAP, BIRP and GIRP notes?
The formats differ mainly in how they split the note. Much of the same wording carries across, and your agency template sets the exact slots. SOAP splits into Subjective, Objective, Assessment and Plan. DAP folds the first two into Data. BIRP is Behavior, Intervention, Response and Plan. GIRP opens with the plan Goal the contact addresses, then Intervention, Response and Plan.
The fuller answer is in SOAP, DAP, BIRP, GIRP Note Formats at a Glance + Abbreviations.
What goes in the Subjective section of a SOAP note?
The client's story in the client's voice. Every sentence names its source: client, collateral contact or record. Use neutral reporting verbs such as reported, stated, described and denied. Quote mood, goals and risk statements when the exact words carry meaning. Quote short phrases, not paragraphs. If tone matters clinically, describe it in the Objective section.
The fuller answer is in Subjective (S) Phrase Guide.
Which words should I avoid in a progress note?
Avoid verbs that carry a judgment: claimed, admitted, complained, refused. Claimed implies you do not believe the client. Admitted implies wrongdoing. Write reported or stated, and declined in place of refused. For a label such as manipulative, write the behavior: requested extra bus passes three times after being told the limit. Test each sentence: could the client read it and call it fair.
The fuller answer is in Informal-to-Clinical Swap List.
How do I write what I saw instead of what I think?
Write what you saw, not what you decided it meant. Write client tearful, voice shaking, and not client was upset. Write did not return call x3, and not avoidant. Put client reports in S with an attribution, what you saw in O, and your professional judgment in A, labeled as your judgment. Use dates, counts and names of agencies in place of adjectives.
The fuller answer is in Mental Status Exam & Objective Language Guide.
How do I document risk and safety in a note?
Document what you asked, what the client said, your risk judgment, what you did about it and who you consulted. Record the question with the answer: when asked about thoughts of suicide and of harming others, client denied both. Cover screening, ideation, plan, intent, access to means, protective factors, your risk judgment and the action taken. Follow your agency's protocol, and bring in clinical consultation any time risk comes up.
The fuller answer is in Risk & Safety Documentation Phrase Guide.
What belongs in the Assessment section?
Your professional judgment: what S and O mean together, how the client is doing against the goals, and why the service is still needed. Most notes fall short here. Do not restate S and O. Interpret them in three parts: clinical impression, progress with evidence, and need and risk level. Hedge what you infer with words such as appears to, is consistent with and suggests.
The fuller answer is in Assessment & Plan Writing Guide.
What should the Plan section say?
Who does what by when. Make each item specific enough that someone covering for you could pick it up. Check the plan against this list: next contact with date and type, client tasks, writer tasks, referrals, coordination, any risk follow-up, and the focus for the next session. For example: Writer will follow up with client on a set date to confirm connection to the referral.
The fuller answer is in Assessment & Plan Writing Guide.
How do I describe how the client responded?
Every intervention needs a response line: how the client engaged and what changed in the session. Pick engagement words that fit, such as receptive, partially engaged, ambivalent or declined. Write declined in place of refused, because it respects the client's choice. When a task was not finished, name what got in the way, not a trait. Add the change you saw, for example anxiety rated 7 out of 10 at the start and 4 at the end.
The fuller answer is in Client Response & Progress Language.
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