Generate a behavioral health session note in SOAP, DAP, BIRP, or GIRP format

Both formats organize clinical documentation into structured sections, but they differ in how they categorize information. A SOAP note uses four sections: Subjective (what the client reports), Objective (clinician observations and measurable data), Assessment (clinical interpretation and diagnosis), and Plan (next steps and treatment direction). A DAP note condenses this into three sections: Data (combining subjective and objective information into a single narrative), Assessment, and Plan. DAP notes are generally faster to write and work well in outpatient settings where medical observations are minimal. SOAP notes are more common in medical-adjacent settings where objective clinical measurements are regularly documented.

A complete behavioral health session note typically includes: the date and duration of the session, the client’s presenting concerns or mood at the start of session, clinician observations of affect and behavior, the therapeutic interventions used and the client’s response, progress toward treatment plan goals, risk assessment where clinically relevant, a plan for the next session or any follow-up actions, and the clinician’s signature and credentials. For billing purposes, notes must also support the CPT code billed, including session length for timed codes like 90837.

This tool generates a structured note template based on the information you provide, but it is your responsibility to review, edit, and individualize the output before adding it to any client record. Generated notes should never be copied verbatim without clinical review. Documentation in a client record is a legal document and must accurately reflect what occurred in the session. Use this tool as a starting point or drafting aid, not as a replacement for your clinical judgment.

An audit-resistant note is specific, individualized, and consistent with the CPT code billed. Key elements include: accurate session start and end times (required for timed codes), a clear description of the presenting concern and client-reported status, specific therapeutic interventions rather than generic labels like “supportive counseling,” documented client response to those interventions, measurable progress or setbacks related to treatment plan goals, and a risk assessment for any client where safety is a concern. Notes that are identical or near-identical across sessions are a major audit red flag. Payers look for individualization that demonstrates medical necessity for each session.

A BIRP note organizes documentation around behavior change rather than medical findings. Its four sections are: Behavior (what the client presented with, including symptoms and self-reported status), Intervention (what the clinician did during the session), Response (how the client responded to those interventions), and Plan (next steps). SOAP notes, by contrast, separate subjective client report from objective clinician observation, making them more common in settings with medical staff. BIRP notes are especially well-suited for outpatient therapy progress notes because they directly tie the clinician’s work to observable client behavior, which strengthens medical necessity documentation.

CPT 90837 covers individual psychotherapy of 53 minutes or more. To support this code, your note must document the actual start and stop time (or total face-to-face minutes), the clinical content of the session including presenting concerns and interventions used, client response and progress, and your plan for continued treatment. The note must also be signed by the treating clinician with their credentials. Some payers additionally require a current treatment plan on file, a diagnosis supported by ICD-10 coding, and documentation of medical necessity. Check your payer contracts for any requirements beyond the CPT definition.