Documentation is a vital part of every provider’s job, and there are several standardized processes that make taking mental health notes more productive and efficient. There are three industry standard notes used in behavioral healthcare, each with a different methodology and purpose: DAP, SOAP, and BIRP. No one methodology of note taking is inherently better than another; however, they do have different use-case in particular settings.
Consistency is important when it comes to clinical documentation, so it’s essential that you pick the right kind of notes for your practice. You should also make sure your practice’s electronic health record (EHR) software has the capability to easily receive and format your notes in the style of your choice. Below, we explore the different notation styles, their naming convention, purpose, and functionality.
What Are SOAP Notes?
SOAP Notes are the most common standardized style, especially since it is the primary form of medical documentation. While common in traditional healthcare settings like a hospital, SOAP notes can also be found in some behavioral health clinics. The letters in SOAP stand for Subjective, Objective, Assessment, and Plan.
Subjective: This section details the information provided directly by the client. This includes their chief complaints as they relate to their wellbeing or area of treatment.
For a physical therapist’s office, this might be detailing a client’s described shoulder pain, and for a CCBHC office, this might detail a client’s description of their thoughts of self-harm.
Objective: This section documents the objective information gathered through medical instruments or physical examination or concrete details of a patient’s experience not influenced by opinion.
This might include a client’s lab results, heart rate, body temperature, and other vital signs typically taken by medical instruments.
Assessment: The assessment section combines the subjective and objective data gathered in a session with the goal of discerning a root cause or a diagnosis for the client through a professional lens. If there are multiple conclusions, they should be listed in order of importance.
This might include a provider diagnosing a client with depression or generalized anxiety.
Plan: In the last section, providers lay out next steps for the client’s treatment based upon the conclusion they reached in their assessment. This may include referrals, specific treatment plans for the diagnosed problems, and the provider’s plan for future sessions.
What Are DAP Notes?
DAP notes are more common in behavioral health practices as they focus on tracking a client’s progress over time versus a specific diagnosis (i.e. SOAP notes.) This style works to combine both subjective documentation from the client with objective data to create a more holistic view of the individual and the purpose of the treatment or therapy plan. Often DAP notes read like a narrative of a client’s therapy journey. DAP stands for Data, Assessment, and Plan.
Data: In this section, providers notate all subjective and objective information about the client and their current state. This includes the client’s own comments on their mood, feelings, perceptions, and behaviors as well as any hard data like test results, pain levels, and how they act within the session.
Assessment: This section describes the provider’s professional assessment of the client based upon the information gathered within the objective section. This sometimes includes a diagnosis, but more often it trends towards general impressions of how the client is doing overall, risk assessments, and any significant developments in their treatment or therapy journey.
Some assessments might include a continued diagnosis of depression with comments on improved overall mood based upon the client’s description of an increase in social activity.
Plan: Similar to SOAP notes, the plan section is where providers detail any next steps for the client to take before their next session as well as details on what the provider may be planning to tackle next time they meet.
These steps should align with goals already communicated between the provider and the client or include updated goals discussed during the session. This could include exercise plans or specific activities to help boost a client’s mood.
What Are BIRP Notes?
BIRP notes are another standard of notetaking in the behavioral health field and focus on quickly documenting information about the client and ensuring all aspects of their treatment journey are documented. BIRP notes are helpful for ensuring a client’s different providers all have the most up-to-date information when they are seen.
Some EHRs have specialized dropdown menus for providers to quickly insert specific observations or assessments. This saves time and helps standardize the notation process, making it easier for other providers to understand.
BIRP stands for Behavior, Intervention, Response, and Plan.
Behavior: This section captures specific notes about a client’s attitude, behavior, and presentation within the session and the observations they report about themselves. Similar to DAP notes, it collects both objective and subjective information in one place but focuses more on client behaviors.
This includes a provider’s impression of the client’s mood and engagement with the treatments and their description of their feelings.
Intervention: In this section, the provider details specific interventions with the client, such as questions asked, why they were asked, and descriptions of therapy exercises that took place. It includes specific details of everything the provider did to further the client’s treatment. Each element of the intervention should link to the problem noted in the behavior section as well as the treatment plan.
Response: The response section details the client’s reaction to each intervention provided. It communicates how the patient replied to questions, their emotional state during discussions or role play exercises. It’s important that this section is as detailed as possible as it records the client’s response to treatment.
Plan: Like SOAP and DAP notes, the plan section describes any activities assigned to the client, as well as the providers strategy for the next session. It’s important for providers to communicate what areas need to be addressed so they can prepare for the next session.
Choosing the Right Notes
It’s difficult to determine what note-taking style is best suited for a particular provider. Clinics often require all providers to follow a certain format to ensure work is easily understood across their organization and to focus documentation on a certain type of treatment. Medical offices often use SOAP notes as they prioritize a diagnosis while mental health professionals typically use DAP to focus on a holistic view of the patient and their progress.
Regardless of the type of documentation, it’s important that a provider’s EHR supports its integration intuitively. Note-taking within an EHR that is poorly designed can lead to human errors, frustration, and a lack of efficiency. Qualifacts suite of behavioral healthcare solutions supports each of these note-taking formats with an optimized and effortless documentation experience.
