SOAP vs. DAP vs. BIRP Notes: Mental Health Progress Note Examples

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1) What’s the Difference Between SOAP, DAP, and BIRP Notes?

SOAP, DAP, and BIRP are organizational frameworks for progress notes. Each helps clinicians arrange information, but each emphasizes a different part of the encounter.

Format	Sections	Main organizational feature	Common challenge
SOAP	Subjective, Objective, Assessment, Plan	Separates client reports from clinician observations	Interventions can disappear unless the template gives them a clear home
DAP	Data, Assessment, Plan	Combines reported and observed information into one clinical account	Data can become an overly long session summary
BIRP	Behavior, Intervention, Response, Plan	Makes clinician actions and client responses easy to locate	Clinical interpretation and goal progress can become too implicit

The central difference in SOAP vs DAP notes is that SOAP separates subjective information from objective observations. DAP places both in Data, while keeping clinical interpretation in Assessment.

BIRP takes another approach: it gives interventions and responses their own sections. That structure can make it easier to see what the clinician did and how the client responded.

None of these acronyms automatically produces a complete note. A well-organized record can still omit the treatment goal, describe an intervention vaguely, or make a claim that the session doesn’t support. Your organization, electronic health record, payer, or practice setting may require particular fields or a specific format. Use the examples below as educational models and adapt them to those requirements.

Start With the Same Clinical Questions

Before choosing headings, ask:

• What concern affected the client’s functioning?
• Which treatment goal did the session address?
• What did the clinician actually do?
• How did the client respond?
• What supports the assessment of progress or continuing need?
• What will happen before or during the next appointment?

These questions keep the note focused on care. NASW’s ethical standards similarly emphasize accurate, timely documentation that supports continuity of services and includes information directly relevant to service delivery.

For a broader view of how progress notes fit into practice paperwork, see The Must-Have Documents Every Therapist Needs for Private Practice.

2) A Fictional Therapy Session To Illustrate All Three Progress Note Examples

To compare formats fairly, we need the same session facts. Otherwise, it’s difficult to tell whether the difference comes from the structure or from changes in the clinical content.

Meet Jordan, a fictional adult client receiving outpatient therapy for an established diagnosis of generalized anxiety disorder.

Shared Encounter Information

The following information applies to all three examples:

• Client: Jordan, age 34.
• Date: October 12, 2026.
• Service: Individual psychotherapy, in person.
• Session time: 10:00–10:50 a.m., 50 minutes.
• Diagnosis: Generalized anxiety disorder, previously established.
• Treatment objective: Over six weeks, reduce nights when worry delays sleep from six per week to two or fewer.
• Next appointment: October 19, 2026.

In a real record, include required client identifiers, clinician credentials, authentication, and any additional administrative or billing fields.

What Jordan Reported

Jordan described anxiety about a new work assignment and said, “If I ask for clarification, they’ll think I can’t do my job.”

Worry delayed sleep on four nights during the previous week, compared with six nights at the treatment baseline. Jordan also postponed two work submissions while repeatedly checking them for mistakes.

At the beginning of the session, Jordan rated anxiety as 7 out of 10.

What the Clinician Observed and Did

Jordan was oriented to person, place, time, and situation. Speech was clear and normally paced, thought processes were linear, and Jordan intermittently fidgeted while discussing work.

The clinician used cognitive behavioral therapy to examine Jordan’s prediction about asking for clarification. Together, they reviewed supporting and contradictory evidence, developed an alternative statement, practiced paced breathing, and selected a ten-minute task-starting step.

Jordan generated the alternative statement with prompting: “Asking a specific question can help me complete the assignment accurately.”

After practice, Jordan rated anxiety as 5 out of 10. Jordan agreed to practice paced breathing for five minutes on four days, track nights when worry delayed sleep, and try the ten-minute work step once before the next appointment.

Safety Information Used in These Examples

During a focused safety assessment, Jordan denied current suicidal or homicidal thoughts, intent, or plans, denied recent self-harm, and reported no history of suicide attempts. Jordan identified a supportive partner and future work commitments as protective factors. The clinician identified no acute safety concerns and planned continued outpatient care and ongoing reassessment.

These fictional findings illustrate documentation of an assessment that occurred. They aren’t a universal risk-assessment template, and they shouldn’t be copied into another client’s record.

SOAP Note Example: Separate Reports, Observations, and Interpretation

SOAP stands for Subjective, Objective, Assessment, and Plan. Its main advantage is the distinction between what the client reports and what the clinician observes.

S: Subjective

Subjective information includes the client’s description of symptoms, experiences, concerns, and perceived changes. Relevant quotations can help preserve the client’s perspective, although every statement doesn’t need quotation marks.

Example: Jordan reported work-related worry and stated, “If I ask for clarification, they’ll think I can’t do my job.” Worry delayed sleep on four nights this week, compared with six nights at baseline. Jordan reported postponing two work submissions because of repeated checking. Anxiety was rated 7/10 initially and 5/10 after in-session practice.

Why this works: The section identifies the concern, its functional effects, and a measurable comparison. It also makes clear that the anxiety ratings and sleep information came from Jordan.

A number doesn’t become objective simply because it looks precise. A client’s self-rated anxiety remains subjective information.

O: Objective

Objective information includes relevant observations and observable session activity. Many SOAP templates also place interventions and demonstrated responses here; other organizations provide a separate intervention field.

Example: Jordan was oriented to person, place, time, and situation. Speech was clear and normally paced; thought processes were linear. Intermittent fidgeting occurred during discussion of work. Clinician used CBT evidence review to examine the anticipated consequences of requesting clarification, guided development of an alternative statement, taught paced breathing, and collaborated on a ten-minute task-starting step. Jordan practiced breathing and generated an alternative statement with clinician prompting.

Why this works: The reader can identify both the clinical presentation and the service delivered. “Used CBT” becomes more meaningful when the note explains which CBT process occurred.

This section doesn’t claim that Jordan became less anxious based solely on appearing calmer. The self-reported change remains clearly identified in Subjective.

A: Assessment

Assessment explains what the information means clinically. It should connect symptoms, functioning, response, and progress.

Example: Worry and repeated checking continue to interfere with work completion and sleep. Reported sleep interference decreased from six to four nights weekly, indicating partial progress toward the treatment objective; the objective remains unmet. Jordan demonstrated emerging ability to reconsider an anxious prediction with support, although independent use outside session is not yet established. Focused safety assessment elicited denial of current suicidal or homicidal thoughts, intent, or plans, recent self-harm, and past suicide attempts. Identified supports and future orientation, together with current findings, support continued outpatient care; no acute safety concerns identified.

Why this works: The assessment acknowledges improvement without exaggerating it. Jordan practiced a skill successfully with help, but the clinician doesn’t treat that success as proof of independent mastery.

P: Plan

Plan identifies the agreed next steps, follow-up, and intended clinical focus.

Example: Continue weekly psychotherapy. Jordan will practice paced breathing for five minutes on four days, track nights when worry delays sleep, and attempt one ten-minute work-starting step before the October 19 appointment. Next session will review practice, barriers, and independent use of the alternative statement. Continue reassessing symptoms, functioning, and safety.

Why this works: The plan is specific enough to revisit. It also follows directly from the problems and skills addressed during the session.

DAP Note Example: Combine the Session Data, Then Explain Its Meaning

DAP stands for Data, Assessment, and Plan. Clinicians who prefer a connected account of the encounter may find this structure comfortable.

The key is remembering that Data includes more than the client’s story. It should also capture relevant observations, interventions, and responses.

D: Data

Example: Jordan reported work-related worry, repeated checking that delayed two submissions, and worry-related sleep delay on four nights this week, compared with six at baseline. Jordan stated, “If I ask for clarification, they’ll think I can’t do my job.” Jordan was oriented to person, place, time, and situation, with clear, normally paced speech, linear thought processes, and intermittent fidgeting during discussion of work. Clinician used CBT evidence review to examine the prediction, guided an alternative statement, taught paced breathing, and collaborated on a ten-minute task-starting step. Jordan generated an alternative statement with prompting, practiced breathing, and reported anxiety decreasing from 7/10 to 5/10. During focused safety assessment, Jordan denied current suicidal or homicidal thoughts, intent, or plans, recent self-harm, and past suicide attempts; identified a supportive partner and future work commitments.

Annotation: This DAP note example combines client reports and clinician observations without confusing their sources. Phrases such as “Jordan reported,” “clinician used,” and “Jordan generated” help readers follow who said or did what.

Although Data is the longest section, it doesn’t need every topic discussed. The material included here explains the treatment target, intervention, response, and relevant safety findings.

A: Assessment

Example: Anxiety continues to impair sleep and timely work completion. Reduction in reported sleep-delay nights from six to four indicates partial progress, with the treatment objective still unmet. Jordan responded to guided cognitive restructuring and breathing practice, but independent application between sessions remains to be evaluated. Current safety findings, identified supports, and future orientation support continued outpatient care; no acute safety concerns identified. Continued treatment will address persistent functional interference and skill generalization.

Annotation: Assessment interprets the data instead of repeating it. The clinician explains why the observed and reported changes matter, what remains difficult, and what continued treatment will address.

P: Plan

Example: Continue weekly psychotherapy, with follow-up October 19. Jordan will practice paced breathing for five minutes on four days, record nights when worry delays sleep, and try one ten-minute work-starting step. Review completion, obstacles, and independent use of the alternative statement next session. Continue symptom, functioning, and safety reassessment.

Annotation: The plan remains the same as in SOAP because the underlying clinical decisions haven’t changed. A different acronym shouldn’t create different treatment facts.

How Can You Keep DAP Notes From Becoming Too Long?

Use a relevance test before adding another sentence: does this information explain the clinical concern, intervention, response, assessment, or plan?

For example, Jordan may have discussed several conversations with coworkers. The note can capture the clinically relevant pattern, fear of appearing incompetent, without recording everyone’s names or reconstructing each exchange.

That editing step often makes DAP documentation easier to read without stripping away its clinical substance.

BIRP Note Example: Make the Intervention and Response Easy to Find

BIRP stands for Behavior, Intervention, Response, and Plan. Its separate Intervention and Response sections encourage clinicians to document the relationship between the service provided and what happened afterward.

“Behavior” doesn’t mean this section is limited to visible actions. Depending on the template, it can include relevant symptoms, client reports, functioning, and presentation.

B: Behavior

Example: Jordan reported work-related worry, repeated checking that delayed two submissions, and worry-related sleep delay on four nights this week versus six at baseline. Jordan stated, “If I ask for clarification, they’ll think I can’t do my job,” and rated initial anxiety 7/10. Jordan was oriented to person, place, time, and situation; speech was clear and normally paced, thought processes were linear, and intermittent fidgeting occurred during discussion of work. Focused safety assessment elicited denial of current suicidal or homicidal thoughts, intent, or plans, recent self-harm, and past suicide attempts. Jordan identified a supportive partner and future work commitments. No acute safety concerns identified.

Annotation: This section establishes the presenting problem and relevant context. It describes functioning rather than relying on “client appeared anxious,” which tells the reader relatively little.

I: Intervention

Example: Clinician used CBT evidence review to examine Jordan’s prediction about requesting clarification and guided development of an alternative statement. Clinician taught and rehearsed paced breathing and collaborated with Jordan to select a ten-minute task-starting step addressing work avoidance and checking-related delay.

Annotation: The intervention section identifies specific clinician actions and their purpose. It connects the techniques to Jordan’s actual difficulties.

Compare that with “provided support and coping skills.” The shorter phrase doesn’t explain which skills were taught or why they were relevant.

R: Response

Example: Jordan identified evidence that a clarification question could improve task accuracy and generated an alternative statement with prompting. Jordan completed breathing practice and reported anxiety decreasing from 7/10 to 5/10. Reported sleep-delay nights decreased from six at baseline to four, reflecting partial progress toward the sleep objective, while work interference persists. Independent use of the skills remains to be assessed. Jordan agreed to between-session practice.

Annotation: Strong BIRP note examples distinguish an immediate response from broader treatment progress. Jordan’s anxiety rating changed during the encounter, while sleep progress reflects the period between appointments.

The section also includes clinical interpretation. Because BIRP has no separate Assessment heading, reasoning about progress and continuing needs must still appear in the record.

P: Plan

Example: Continue weekly outpatient psychotherapy; next appointment October 19. Jordan will practice paced breathing for five minutes on four days, track nights when worry delays sleep, and attempt one ten-minute work-starting step. Review barriers, symptom changes, and independent skill use next session. Continue reassessment of functioning and safety.

Annotation: The plan states what Jordan and the clinician will revisit. It also preserves the same decisions documented in the SOAP and DAP versions.

3) What Actually Changes When You Switch Formats?

The placement changes. The clinical facts, degree of certainty, and treatment decisions should remain consistent.

Information from Jordan’s session	SOAP	DAP	BIRP
Reported sleep difficulty and work delays	Subjective	Data	Behavior
Observed speech, thought process, and fidgeting	Objective	Data	Behavior
CBT evidence review and breathing instruction	Objective or designated intervention field	Data	Intervention
Demonstrated skill practice	Objective	Data	Response
Client-reported anxiety reduction	Subjective	Data	Response
Interpretation of partial progress	Assessment	Assessment	Response and/or Plan, according to template
Between-session practice and follow-up	Plan	Plan	Plan

This comparison reveals a common documentation problem: a clinician may know the information belongs somewhere but leave it out because there isn’t an obvious heading.

SOAP still needs interventions. DAP still needs client responses. BIRP still needs clinical reasoning!

For clinicians developing those skills, Agents of Change Continuing Education offers more than 200 courses through its ASWB ACE and NBCC-approved continuing education program for Therapists, Social Workers, Counselors, and Mental Health Professionals seeking credits toward license renewal. Its subscription also includes 25+ live continuing education events each year, averaging more than one per month.

How to Describe Interventions Without Filling the Note With Jargon

An intervention statement should help another clinician understand what happened. Naming a modality can provide context, but the modality alone doesn’t describe the service.

Move From a Broad Label to a Specific Action

Consider these documentation improvements:

Broad wording	More informative wording
Used CBT	Guided the client in examining evidence for and against an anticipated negative outcome
Provided psychoeducation	Explained how repeated checking can prolong task completion and maintain worry
Worked on coping skills	Taught paced breathing and guided an in-session practice
Addressed communication	Rehearsed a specific request for clarification using role-play
Discussed barriers	Explored how shift changes prevented the client from attending the scheduled group

The improved statements don’t need to sound elaborate. They identify an action, its focus, and, when helpful, its connection to treatment.

Keep the Client’s Response Separate From Your Intent

A clinician may intend an exercise to reduce distress. The client may experience no change, find it uncomfortable, or prefer another strategy.

Document the response that occurred: Client completed the exercise and reported no change in distress. Clinician explored the client’s experience and agreed to revisit strategy selection next session.

That sentence provides useful information for future care. There’s no need to manufacture a positive result to make the intervention appear worthwhile.

How to Document Progress Without Overstating It

Progress can be uneven. A client may understand a concept before using it independently, report fewer symptoms while still struggling at work, or complete a meaningful task while feeling considerable distress.

Your note should preserve those distinctions.

Use a Meaningful Comparison

“Client is improving” leaves several questions unanswered. Improving in what way? Compared with when? Based on whose report?

More useful language includes:

• “Client reported worry-related sleep delay on four nights, compared with six at baseline.”
• “Client identified an alternative interpretation with two clinician prompts.”
• “Client attempted the planned conversation but ended it early because of distress.”
• “Symptoms remained unchanged; client identified scheduling barriers to between-session practice.”

A treatment objective gives these observations a reference point. Without one, it’s easy to confuse participation with progress.

For help creating goals that can be revisited meaningfully, see Effective Client Goal-Setting Techniques for Therapists and Social Workers.

Explain Why Continuing Care Makes Sense

In Jordan’s case, improvement in sleep doesn’t erase the continuing work delays or the need for prompting during cognitive restructuring. The note can recognize early gains and explain the remaining clinical needs in the same paragraph.

Where medical necessity must be supported, the record should make the relationship among symptoms, functional difficulties, skilled treatment, and the plan understandable. Exact requirements depend on the applicable service and payer; an acronym alone doesn’t establish them.

4) How Much Detail Is Enough for Progress Notes?

A progress note needs enough information to support care without turning into a transcript. Jordan’s exact workplace, supervisor’s name, and assignment content aren’t necessary for understanding the documented intervention. The relevant information is that fear of appearing incompetent contributed to checking, delayed submissions, and sleep disruption.

Include Context When It Changes the Clinical Meaning

Concise documentation should still acknowledge relevant circumstances. For example, “client did not complete practice” means something different when the client lacked privacy, worked an unexpected overnight shift, or couldn’t access translated instructions.

Describe the barrier and its effect on the plan. That gives the next session somewhere useful to begin.

Use Respectful, Descriptive Language

Instead of labeling a client “resistant,” describe the response: Client declined role-play, explaining that practicing the conversation felt overwhelming. Clinician explored the concern and offered a written preparation exercise.

This wording documents the client’s choice, the relevant context, and the clinician’s adaptation. It also avoids treating disagreement as a personality characteristic.

Agents of Change Continuing Education includes a training titled “Writing With, Not Just About, Clients: Person-Centered Clinical Documentation in Behavioral Health.” Find it in the course catalog for further learning about collaborative, person-centered documentation.

Progress Notes and Psychotherapy Notes Aren’t Interchangeable

A note documenting psychotherapy isn’t automatically a “psychotherapy note” under HIPAA.

HHS describes psychotherapy notes as a specific category documenting or analyzing counseling conversations and maintained separately from the rest of the medical record. The definition excludes summaries of diagnosis, symptoms, functional status, treatment plans, and progress, among other routine record information.

The SOAP, DAP, and BIRP examples here illustrate clinical progress notes. Selecting one of these formats doesn’t create a separate category of protected personal process notes. That distinction matters when deciding what belongs in the clinical record and how records are maintained or disclosed.

Common Progress Note Mistakes and Practical Fixes

Writing a Topic List Instead of a Clinical Note

“Discussed work, relationships, sleep, and stress” identifies topics but leaves out the treatment. Add the intervention, response, and connection to the goal. A reader should understand what made the encounter a clinical service.

Using “Receptive” as the Entire Response

“Client was receptive” can mean almost anything. Did the client ask questions, demonstrate a skill, identify a concern, or agree to try something? Instead, choose the description that reflects what happened. “Client practiced the skill with prompting” is more informative and more modest.

Copying Last Week’s Assessment

A copied note may retain an outdated symptom rating, safety statement, or plan. Even when the treatment approach stays consistent, the current encounter needs its own accurate documentation. Templates can hold the structure. Review and update the content.

Making Every Session Look Successful

A record filled with immediate improvement can obscure setbacks, barriers, and uncertainty. Document limited response or worsening symptoms when present, along with the clinical reasoning and follow-up. Honest documentation makes treatment easier to evaluate.

Accepting an AI Draft Without Checking Its Claims

An AI-generated note may add an intervention, assume a risk assessment occurred, or make the client’s response sound more positive than it was. Verify every clinical statement before signing. For a fuller discussion, read The Ethics of AI Documentation in Mental Health Practice.

A Quick Review Before You Sign

Before finalizing a note, check the following:

1. Accuracy: Does every statement reflect information obtained or care provided?
2. Source: Can the reader distinguish client reports from clinician observations?
3. Intervention: Is the clinician’s action specific enough to understand?
4. Response: Does the note explain how the client responded?
5. Progress: Is the assessment connected to a goal or meaningful comparison?
6. Safety: Does the documentation accurately reflect relevant assessment and follow-up?
7. Plan: Are the next steps clear and connected to the encounter?
8. Relevance: Can unnecessary sensitive details be removed?
9. Completion: Are required encounter fields and authentication present?

This review can be brief once the structure becomes familiar. The aim is a useful, accurate note that you can complete consistently.

Continuing Education That Supports Better Documentation

Documentation skills develop through practice, feedback, and opportunities to examine clinical reasoning. Reviewing a few notes with a supervisor or colleague can reveal patterns, such as vague interventions or plans that never change.

For clinicians looking for the most affordable option available for their CEUs, Agents of Change Continuing Education offers a strong-value $99/year subscription. It includes access to a growing library of 200+ ASWB and NBCC-approved courses, 25+ live events annually, unlimited opportunities to earn credits, and additional learning resources, with new courses added regularly. Check individual course eligibility against your profession’s and licensing board’s requirements.

5) FAQs – SOAP vs. DAP vs. BIRP Notes

Q: What’s the Difference Between SOAP, DAP, and BIRP Notes in Mental Health?

A: SOAP notes organize information into Subjective, Objective, Assessment, and Plan, separating the client’s reports from the clinician’s observations.

DAP notes combine reports, observations, interventions, and responses in Data, followed by Assessment and Plan.

BIRP notes use Behavior, Intervention, Response, and Plan to make the clinician’s actions and the client’s reactions easier to identify. Each format can support effective documentation when it captures clinical reasoning, progress toward treatment goals, and appropriate next steps.

Q: What Should a Mental Health Progress Note Include?

A: A mental health progress note should identify the relevant symptoms and functional concerns, the interventions provided, the client’s response, and progress toward treatment goals. Include clinical assessment, relevant safety findings, and a specific follow-up plan, along with required encounter details and authentication.

Describe what actually occurred, distinguishing client reports from clinician observations and interpretations. Include enough context to support care while avoiding unnecessary sensitive details or a transcript of the session.

Q: Is SOAP, DAP, or BIRP Better for Insurance Documentation?

A: No format automatically guarantees insurance acceptance or establishes medical necessity. Follow the applicable payer’s requirements and clearly connect the client’s symptoms and functional difficulties to the skilled intervention, response, and continuing treatment needs.

SOAP and DAP provide dedicated Assessment sections for clinical reasoning, while BIRP requires that reasoning to appear within its existing sections or additional template fields. Accurate, individualized content matters more than the acronym at the top of the note.

6) Conclusion

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► Learn more about the Agents of Change Continuing Education here: https://agentsofchangetraining.com

About the Instructor, Meagan Mitchell: Meagan is a Licensed Clinical Social Worker and has been providing Continuing Education for Social Workers, Therapists, and Counselors for more than 10 years. From all of this experience helping others pass their exams, she created Agents of Change Continuing Education to help Social Workers, Therapists, and Counselors stay up-to-date on the latest trends, research, and techniques.

Disclaimer: This content has been made available for informational and educational purposes only. This content is not intended to be a substitute for professional medical or clinical advice, diagnosis, or treatment