The 7 Types of Progress Notes in Therapy (SOAP, DAP, BIRP & More) + Examples

Therapists use 7 main types of progress notes: SOAP, DAP, BIRP, GIRP, PIE, DARP, and APSO. Each format documents therapy sessions differently, and picking the wrong one for your setting creates compliance gaps, slows documentation, and complicates billing.

This guide covers all 7 formats with definitions, real examples, and best practices. You will also find a breakdown of mental health progress notes versus psychotherapy notes, the difference between progress notes and process notes, and a section on clinical language for progress notes — distinctions that create problems for a lot of clinicians.

What Are Progress Notes in Therapy?

Progress notes are official clinical records that document what happened during a therapy session. They include the client’s presentation, the therapist’s observations, clinical impressions, and the plan for next steps.

Therapists, psychologists, licensed counselors, social workers, and psychiatrists all use them across every clinical setting: private practice, community mental health centers, inpatient units, and telehealth.

Progress notes are not optional. They are a legal requirement for licensed mental health professionals and a permanent part of the client’s medical record.

Why Progress Notes Matter in Mental Health Documentation

Progress notes protect your license, support billing, and keep care consistent. Here is what they specifically do:

• Legal protection: If a client’s care is ever disputed or reviewed, your notes are the documented record of what you did and why.
• Insurance reimbursement: Miss a required field, and the claim comes back denied. Insurers will not pay without documentation that meets their standards.
• Treatment continuity: Another provider should be able to pick up right where you left off. That only works if your notes are clear and current.
• Clinical communication: Your notes are how the rest of the team stays informed. Psychiatrists, case managers, and supervisors all rely on what you write.
• Audit readiness: Records can be requested without warning. Solid notes mean you are never caught off guard.
• Risk management: When safety concerns come up, your notes are proof that you addressed them. That matters legally and clinically.

What Should Be Included in a Progress Note?

Every therapy progress note should cover these:

• Client name, date of birth, session date
• What the client reported: mood, concerns, symptoms
• What you observed: appearance, affect, behavior
• Your clinical read: progress, diagnostic impressions
• The plan: next steps, homework, referrals
• What approach you used: CBT, DBT, EMDR, etc.
• Risk assessment, even if nothing came up
• Your signature, credentials, and date

Progress Notes vs Psychotherapy Notes

Progress notes and psychotherapy notes are not the same thing. One goes in the official record. The other stays private. Mixing them up puts you at risk under HIPAA.

Feature	Progress Notes	Psychotherapy Notes
Purpose	Official clinical documentation	Private therapist reflections
HIPAA Status	Part of the official medical record	Separately protected, stricter access rules
Who Can Access	Insurers, supervisors, treatment team	Usually only the treating therapist
Content	Standardized clinical format	Personal impressions, hypotheses, reactions
Required?	Yes, for licensed practice	No, kept at therapist’s discretion

 

Progress Notes vs Process Notes

A question that comes up often: what is the difference between progress notes and process notes?

Progress notes are the official clinical record of each session. They use a structured format (SOAP, DAP, BIRP, etc.), stay in the client’s chart, and are accessible to insurers, supervisors, and the treatment team.

Process notes, also called psychotherapy notes, are the therapist’s private working document. They may include countertransference reactions, hypotheses about client dynamics, personal observations, and reflective material that does not belong in the official record. Process notes in therapy are not part of the medical record and carry stronger HIPAA protections.

The key rule: never mix the two. If your personal clinical reflections end up in the official progress note, they become accessible to parties who should not see them.

The 7 Types of Progress Notes Used by Therapists

No single format works for every clinical setting. The type of therapy notes you use should match your environment, billing requirements, and caseload.

Here are all 7 types of progress notes used in mental health practice, plus two additional formats — DAPT and GDAP — used in case management and structured therapy programs.

1. SOAP Notes

SOAP notes are a type of progress notes that use a four-part structure that works in any setting where multiple providers read the same clinical record. They are the most widely recognized documentation format in both healthcare and therapy.

SOAP stands for Subjective, Objective, Assessment, and Plan. The format comes from medicine, which is why it stays common in integrated health settings, hospital-based programs, and multidisciplinary teams.

SOAP Note Format Explained

Subjective (S): What the client reports in their own words — feelings, complaints, and symptom descriptions.

Example: “Client stated she has been feeling anxious every morning before work.”

Objective (O): What the therapist directly observes: appearance, mood, affect, behavior, and psychomotor activity.

Example: “Client appeared tense, spoke rapidly, and made limited eye contact.”

Assessment (A): The therapist’s clinical interpretation. How is the client progressing? Are symptoms improving? Is there any risk?

Example: “Client’s anxiety appears moderately elevated, consistent with reported life stressors.”

Plan (P): What you are doing next: session focus, homework, any referrals, medication follow-ups, or adjustments.

SOAP Notes Example

Client: Adult female, 34 | Diagnosis: Generalized Anxiety Disorder

Subjective: Client said anxiety has been worse this week, rating it 8/10. She kept coming back to fears about losing her job. Sleep has been off, and focus at work is suffering

Objective: Client presented as alert and oriented. Appeared visibly tense with raised shoulders and frequent fidgeting. Speech was rapid. Mood was anxious, and affect matched. No signs of psychosis. No suicidal ideation.

Assessment: Anxiety is still sitting at moderate to severe. Job-related worry is driving most of it, and catastrophic thinking came up repeatedly. She has not made much ground yet toward her anxiety goals.

Plan: Staying with CBT and working on how she frames worst-case scenarios. Left with a thought record to fill out before next week. Sleep will be checked at the next visit.

What Is Objective Content in Therapy Notes?

A common question therapists have when using SOAP format is what actually counts as objective content. Objective content in therapy notes refers only to things directly observable and verifiable by a third party. It does not include your interpretation of what you see — that belongs in the Assessment section.

Objective content examples for therapy notes:

• Appearance: well-groomed, disheveled, appropriate dress for weather
• Psychomotor: psychomotor retardation, agitation, restlessness, tremor
• Speech: rapid, pressured, slow, monotone, coherent, disorganized
• Affect: flat, blunted, labile, congruent with stated mood, expansive
• Eye contact: good, poor, avoidant, intense
• Thought process: logical, tangential, circumstantial, flight of ideas

The rule: if you cannot verify it by direct observation, it is subjective, not objective.

When to Use SOAP Notes

• Works well in medical or integrated care settings
• Standard in hospital-based mental health programs
• Good fit when physicians or other providers are reading the same notes
• Useful anywhere documentation needs to be structured and easy to audit

2. DAP Notes

What does the ‘D’ in DAP note stand for? The D stands for Data — a combined section that captures both the client’s self-report and the therapist’s direct observations in one place. This is the defining difference between DAP and SOAP notes.

DAP stands for Data, Assessment, and Plan. The three-section structure cuts redundancy and suits therapists who need to document efficiently across a full caseload. It is the go-to format in private practice and outpatient counseling.

DAP Note Format

Data (D): What the client said and what you observed, all in one place. This is what sets DAP apart from SOAP.

Assessment (A): Your clinical take — how the client is progressing, diagnostic picture, risk factors, and treatment response.

Plan (P): What comes next: session focus, interventions, homework, referrals, or changes to the treatment plan.

DAP Note Example

Client: Adult male, 28 | Presenting concern: Depression and social isolation

Data: Client came in and reported finishing his homework — he scheduled a social outing and actually went to a family dinner. Mood was 5/10, up from 3/10 the week before. Eye contact was better, and he seemed more present than usual. Still dragging in the mornings and struggling to stay motivated at work.

Assessment: The behavioral activation work is starting to land. His mood is ticking up, and he engaged socially twice this week. Negative self-talk around worthlessness is still there. No thoughts of suicide.

Plan: Keep building on social engagement. Start introducing ways to challenge the negative self-talk. Journaling is assigned to track mood alongside activity. Check in on progress next session.

Difference Between DAP and SOAP Notes

The main difference between SOAP and DAP notes is how they handle subjective and objective information. DAP combines both into a single Data section; SOAP keeps them in separate S and O sections. This makes DAP faster to write and a better fit for outpatient counseling, while SOAP works better in medical settings where other providers need to distinguish clearly between client report and clinician observation.

Feature	SOAP Notes	DAP Notes
Structure	4 sections (S, O, A, P)	3 sections (D, A, P)
Subjective and Objective	Kept separate	Combined into Data
Complexity	More detailed	Faster to write
Best Use	Medical and team settings	Private practice, outpatient
Popularity	High in healthcare	High in counseling settings

 

3. BIRP Notes

BIRP notes are a type of progress note that documents what the therapist did and how the client responded. They are the right format for behavioral health settings where tracking outcomes matters.

What does BIRP stand for? BIRP stands for Behavior, Intervention, Response, and Plan. The format was originally developed for community mental health and substance use programs. Unlike SOAP or DAP, BIRP leads with what the client presented behaviorally, then records what the therapist did about it and how the client responded.

BIRP Format Explained

Behavior (B): The client’s presenting behavior, mood, and reported concerns at the start of the session.

Intervention (I): What you actually did in session. Name the technique and describe how you used it.

Response (R): What happened when you used it? Did the client engage, push back, or shift in some way?

Plan (P): What you are carrying into the next session: what to keep, adjust, or introduce.

BIRP Notes Example

Client: Adolescent female, 16 | Diagnosis: ADHD, Oppositional Defiant Disorder

Behavior: Client appeared irritable and defensive at session start. She stated, ‘I don’t see why I have to be here.’ Therapist observed tight body language and raised affect. Client brought up a run-in with a teacher that ended in detention.

Intervention: Used motivational interviewing to explore what she actually wants for herself. Walked through the school situation together and looked at where her reaction escalated things. Tried out a different response using role play.

Response: She pushed back at first, but got into it once the role play started. By the end, she admitted her reaction had made things worse and picked one thing she was willing to do differently.

Plan: Keep going with motivational interviewing. Work on self-regulation again next session. Reach out to the school counselor once the client gives the go-ahead.

When Therapists Use BIRP Notes

• Programs where you need to show measurable progress
• High-acuity community mental health caseloads
• Intensive Outpatient Programs (IOPs) and Partial Hospitalization Programs (PHPs)
• Any billing situation where you have to document what you did and how the client responded

4. GIRP Notes

GIRP notes are a type of progress note that anchors every section of the documentation to a specific treatment goal, making them a natural fit for structured programs where clinical accountability is built into the model.

GIRP stands for Goal, Intervention, Response, and Plan. Substance use programs, rehab centers, and structured outpatient settings tend to use GIRP because every note ties directly back to a treatment goal. You can track progress week by week without losing the thread.

GIRP Format Explained

Goal (G): The specific goal you are working on today, pulled word for word from the treatment plan.

Intervention (I): What you did in the session to move toward that goal.

Response (R): How the client showed up for it. Did they engage? Did they struggle? What came out of it?

Plan (P): What happens next in pursuit of the goal, including adjustments, continuations, or new objectives.

5. PIE Notes

PIE notes are a type of progress note that strips documentation down to three focused sections, used in mental health settings where speed and simplicity matter.

PIE stands for Problem, Intervention, and Evaluation. The format originated in nursing and medical settings. It leads with the identified clinical problem rather than the client’s narrative. Case managers, inpatient psychiatric units, and high-volume settings where multiple providers document for the same client find PIE notes practical.

PIE Format Explained

Problem (P): The clinical issue you are addressing today, tied to the client’s diagnosis or care plan.

Intervention (I): The specific thing you did about it in session.

Evaluation (E): Did it make a difference? Document the client’s response and any shift in their status.

PIE Note Example (Mental Health)

Problem: Client came in anxious about an upcoming court date.

Intervention: Walked through diaphragmatic breathing and a grounding exercise together. Talked through how anxiety builds and why the body reacts the way it does.

Evaluation: Anxiety dropped from 7/10 to 4/10 by the end of the session. Client said she felt steadier. Will practice again next time.

6. DARP Notes

DARP notes are a type of progress note that extends DAP by adding a Response section that captures how the client reacted to in-session interventions — something standard DAP does not document.

DARP stands for Data, Assessment, Response, and Plan. It sits between DAP and BIRP: more detail than DAP, less structure than BIRP. Clinicians managing complex cases who need documented proof of intervention response without adopting a full behavioral framework find DARP notes useful.

DRAP Format Explained

Data (D): Combined client report and therapist observations from the session.

Assessment (A): Clinical interpretation — progress, risk, diagnostic impressions, and treatment response.

Response (R): How the client responded to the therapist’s interventions during the session. This is what separates DARP from standard DAP.

Plan (P): Next session objectives, homework, referrals, or plan adjustments.

7. APSO Notes

APSO notes put the clinical assessment first, so the reader sees your conclusion before the supporting data — making them efficient in fast-paced or medical environments.

APSO stands for Assessment, Plan, Subjective, and Objective. It is a reordered version of SOAP. In settings where providers read notes quickly and need conclusions at the top, APSO reduces reading time without losing clinical content.

APSO Format Explained

Assessment (A): Your clinical interpretation comes first.

Plan (P): The treatment plan follows directly after.

Subjective (S): Then the client’s own report — what they said and experienced.

Objective (O): Finally, your direct observations from the session.

Additional Progress Note Formats: DAPT and GDAP

Beyond the core seven formats, two additional note types come up regularly in case management and structured therapy programs: DAPT and GDAP. If you work in social services, community mental health, or a goal-based treatment model, you may encounter these formats.

DAPT Notes (Data, Assessment, Plan, Task)

DAPT notes are used primarily in case management and social work settings. The format builds on DAP by adding a Task section that documents specific action items assigned to the client, the provider, or a third party.

DAPT stands for Data, Assessment, Plan, and Task.

Data (D): What the client reported and what the case manager observed during the encounter.

Assessment (A): Clinical or case management interpretation of the client’s current status.

Plan (P): The overall direction and goals for the service encounter.

Task (T): Specific action items. Who is responsible? What is the deadline? This is what distinguishes DAPT from standard DAP.

DAPT is particularly common in behavioral health case management, social work documentation, and wraparound service programs where multiple providers or agencies share responsibility for follow-through.

GDAP Notes (Goal, Data, Assessment, Plan)

GDAP notes are a goal-oriented documentation format used in psychotherapy and structured outpatient settings. Every section connects back to a treatment goal, creating a direct line between session activity and the treatment plan.

GDAP stands for Goal, Data, Assessment, and Plan.

Goal (G): The specific treatment goal being addressed in this session, pulled directly from the treatment plan.

Data (D): The client’s self-report and therapist observations relevant to that goal.

Assessment (A): Progress toward the goal, including barriers, strengths, and diagnostic considerations.

Plan (P): Next steps in pursuit of the goal.

GDAP is a strong fit when your clinical setting requires documentation to align tightly with treatment goals, or when supervisors or billing reviewers want to see a clear golden thread — a visible connection between the presenting problem, treatment goals, and every session note.

The Golden Thread in Clinical Documentation

The golden thread in counseling refers to the visible, logical connection that runs through all your clinical documentation — from the initial assessment to the treatment plan to each progress note to discharge. Every note should answer the question: how does what happened in this session connect to why this client is in treatment?

When the golden thread is strong, auditors, supervisors, and payers can follow the clinical logic of the case without filling in gaps. When it is missing, documentation looks disconnected and is harder to defend.

Formats like GDAP and GIRP are explicitly designed to maintain the golden thread by requiring you to name the treatment goal at the top of every note.

Clinical Language for Progress Notes

How you phrase a progress note matters as much as what you document. Vague or subjective language weakens the record. Clinical language for progress notes should be specific, observable, and third-person throughout.

Words and Phrases to Use in Therapy Progress Notes

These are examples of clinical language that reads well in a progress note:

• Client presented as: cooperative, guarded, tearful, agitated, well-groomed, disheveled
• Affect was: flat, blunted, labile, congruent/incongruent with stated mood, expansive, restricted
• Client reported: elevated anxiety, low mood, disrupted sleep, difficulty concentrating
• Client demonstrated: improved insight, resistance to intervention, willingness to engage
• Client responded to intervention by: identifying two alternative thoughts, completing the exercise with prompting, declining to participate
• Therapeutic interventions included: cognitive restructuring, psychoeducation, grounding techniques, motivational interviewing, EMDR processing, behavioral activation
• Client denied: suicidal ideation, homicidal ideation, self-harm urges, substance use
• Treatment goals addressed: as per treatment plan dated [date]

Words to Avoid in Progress Notes

These terms weaken your documentation:

• ‘Doing well’ — not observable or measurable
• ‘Seemed sad’ — use specific affect descriptors instead
• ‘Had a good session’ — document what happened, not how it felt
• ‘Is depressed’ as a standalone observation — document observable signs and client report
• ‘Was defiant’ — instead write: ‘client refused 4 of 6 tasks and placed head on desk for approximately 2 minutes after each request’
• Abbreviations your agency has not approved — spell them out or use standard clinical shorthand

How to Write Therapy Progress Notes (Step-by-Step)

Writing good therapy progress notes requires a consistent process. These four steps apply across all formats and keep documentation accurate, compliant, and efficient.

Step 1 — Capture Subjective Information

Start with what the client reported during the session. Write in third-person clinical language throughout. ‘Client reported feeling overwhelmed’ is correct. ‘She said she’s overwhelmed’ is not.

Include:

• Mood and energy level as reported by the client
• Symptoms mentioned: sleep, appetite, concentration, anxiety, etc.
• Significant life events or stressors since the last session
• Direct quotes, used sparingly, when they carry clinical weight

Step 2 — Document Objective Content

Objective content in therapy notes should only include what is directly observable and measurable — things a third party could verify. Avoid vague descriptors like ‘seemed sad.’ Write instead: ‘Client’s affect was flat; she made minimal eye contact and spoke in a monotone.’

Document:

• General appearance: grooming, dress, hygiene
• Psychomotor activity: agitation, slowing, restlessness
• Speech: rate, volume, coherence
• Mood as reported and affect as observed
• Thought process and content: logical, tangential, disorganized
• Cognitive functioning: orientation, memory, concentration

Step 3 — Write Clinical Assessment

The assessment section is where your clinical judgment goes. Connect the session data to a clinical conclusion. Do not just summarize what happened — explain what it means for the client’s care.

Include:

• Progress toward specific treatment goals
• Clinical interpretation of patterns or themes from the session
• Risk assessment: document suicidal ideation, self-harm, or substance concerns explicitly, even when denied
• Diagnostic impressions if symptoms are shifting or new concerns emerge
• The client’s response to the interventions used in the session

Step 4 — Create the Treatment Plan

Every therapy progress note should close with a specific, action-oriented plan. ‘Continue therapy’ is not a plan. ‘Continue CBT focusing on decatastrophizing; client will complete a daily thought record before next session’ is.

Checklist for the plan section:

• Next session date and focus area
• Homework or between-session tasks assigned
• Modality or technique to be used in the next session
• Referrals made or pending
• Medication follow-up if applicable

Real Therapy Progress Notes Examples

Three sample progress notes for therapy, written in realistic clinical language.

Example 1 — SOAP Progress Note

Client: Adult male, 42 | Diagnosis: Major Depressive Disorder, recurrent, moderate

Subjective: Client said this week was hard. He mentioned sleeping 12 hours a day and still feeling drained. He does not feel ready to go back to work. No suicidal thoughts. Appetite is unchanged.

Objective: Looked unkempt. Spoke slowly with long pauses. Flat affect. Poor eye contact. Called his mood ’empty.’ No agitation or unusual perceptions noted.

Assessment: Depression is still moderate to severe. He is sleeping too much, moving slowly, and not engaging much with treatment. Work functioning is down. No safety concerns right now.

Plan: Keep going with interpersonal therapy around work and life changes. He agreed to a 10-minute walk each day as a starting point. Sent referral to psychiatry for a medication check. Back in one week.

Example 2 — DAP Progress Note

Client: Adult female, 29 | Diagnosis: PTSD, Panic Disorder

Data: Client appeared more engaged than in the last session. She tried her grounding exercise during a panic attack this week and said it helped somewhat, bringing panic from 9/10 to 6/10. A work situation brought up memories related to her trauma. Eye contact and speech were noticeably better. No avoidance reported.

Assessment: Grounding skills are starting to work. PTSD symptoms are still present, but she is making the connection between current triggers and past trauma. That is a good sign for starting EMDR. No safety concerns.

Plan: Start EMDR phase 1 psychoeducation in the next session. Keep practicing grounding skills. Assigned a body scan to try at home. Talked through how to handle the work event coming up. Next session is confirmed.

Example 3 — BIRP Progress Note

Client: Adult male, 51 | Diagnosis: Alcohol Use Disorder, Moderate

Behavior: Client walked in rattled. He had been drinking again — four times over the past week, after three clean weeks. Said he just gave up. Kept his eyes down and barely spoke above a whisper. No safety concerns.

Intervention: Used motivational interviewing to look at the relapse without blame. Did a decisional balance exercise to weigh drinking versus staying sober. Talked through what situations put him at risk and what coping options he had but did not use.

Response: He opened up more as the session went on. Named two triggers he had never mentioned before. Admitted he did not follow his coping plan when things went sideways.

Plan: Rework the relapse prevention plan to include the new triggers. Practice coping responses together next session. Get his AA sponsor looped in for backup. He committed to two meetings this week. Next session booked.

Common Mistakes to Avoid When Writing Progress Notes

These documentation errors are the most common and the most damaging:

• Being too vague: ‘Client doing well’ and ‘Session was productive’ have no clinical value. Notes need specific, observable detail.
• Over-documenting: A progress note is not a session transcript. Comprehensive means covering what matters, not everything that was said.
• Missing risk documentation: If you assess safety, document it. Write ‘Client denied suicidal ideation’ even when the answer is no.
• Mixing subjective and clinical language: ‘Client is depressed’ is a clinical conclusion. ‘Client reported feeling depressed’ is documentation. Know the difference.
• Copy-pasting previous notes: Reusing prior notes without updating them is a HIPAA violation and a red flag in any audit.
• Incomplete signatures: Full name, credentials, and date of service must appear on every note. Missing any of these can trigger a denied claim.
• Late documentation: Notes written days after a session are harder to defend. Write them the same day.
• Confusing progress notes and process notes: Personal impressions, countertransference reactions, and speculative hypotheses belong in process notes, not the official record.

Best Practices for Faster, Compliant Documentation

These habits cover how to write therapy notes efficiently without cutting clinical corners.

1. Write immediately after each session or within 24 hours. The longer you wait, the less accurate the note becomes.
2. Use a template for your chosen format. Templates eliminate blank-page hesitation and keep notes consistent across your caseload.
3. Keep language clinical throughout. No slang, no unexplained abbreviations, no casual phrasing.
4. Keep progress notes and psychotherapy notes separate. Personal impressions and countertransference belong in a different document.
5. Know your payer requirements. Medicare, Medicaid, and private insurers each have their own documentation standards.
6. Only document what actually happened. Do not record interventions you did not use or observations you did not make.
7. Maintain the golden thread. Every note should connect to the treatment goals in the client’s care plan.
8. Protect third-party information. Do not include details about people other than the client without their consent.

Choosing the Right Format for Your Practice

The right type of therapy progress note depends on where you work, who you serve, and what your billing and compliance requirements are.

SOAP fits structured medical environments. DAP suits outpatient counseling and private practice. BIRP is built for behavioral health and outcome tracking. GIRP keeps documentation tied to treatment goals. PIE works in fast-paced or team-based settings. DARP adds intervention tracking to the DAP structure. APSO is for clinicians who need conclusions first. DAPT is the standard for case management settings. GDAP is ideal when documentation needs to align tightly with treatment goals across every session.

Use your chosen format consistently. Inconsistent documentation is harder to audit, harder to defend, and harder to rely on as a clinical tool.

 

Frequently Asked Questions