Writing Progress Notes
Note Formats
TherapyOneClinic supports four popular note formats:
1. SOAP Notes
- S - Subjective: Patient's reported experience
- O - Objective: Observable facts and measurements
- A - Assessment: Clinical impression and diagnosis
- P - Plan: Treatment plan and next steps
2. DAP Notes
- D - Data: Observations and patient statements
- A - Assessment: Clinical analysis
- P - Plan: Treatment recommendations
3. BIRP Notes
- B - Behavior: Observed behaviors
- I - Intervention: Therapeutic techniques used
- R - Response: Patient's response to intervention
- P - Plan: Future treatment plan
4. Narrative Notes
Free-form documentation of the session.
Best Practices
- Complete notes within 24 hours of the session
- Be objective and factual
- Use professional language
- Document risk assessments when appropriate
- Include diagnosis codes
- Sign and date all notes
Using Templates
Create custom templates for common situations to save time while maintaining quality.