Imagine this, you just finished a meeting with a client and you answered all the client's questions, then you just checked out of your office to see that there are tens of patients waiting for a consultation appointment with you at the reception hall; you also have follow-up emails to send to other clients and you have an errand to run during your break time before your next appointment. At the end of your day, take a moment to review the rushed therapy notes you wrote earlier, trying to understand what you were actually trying to convey. It looks familiar, right?
Most therapists know the importance of taking therapy notes. They are not random jotted-down notes; they are a manual to track the progress of every patient and their treatment, allowing you to meet their objectives. But the ability to write good therapy notes that summarize and report information coherently and efficiently cannot be possessed by all therapists.
That is why in this article, we will guide you on how to write therapy notes effectively, with examples and templates. We will even show you how to use a tool like Plaud Notepin to help you ease the process of writing a therapy note. Let's dive in.
The importance of therapy notes
As a therapist, therapy notes have become so vital in our day-to-day work. You must maintain therapy notes, as failing to do so can reflect poorly on you as a therapist. When working with patients, tracking results is essential to demonstrate that you are making a positive impact.
Therapy notes show that you not only do your work well, but you also care about the patient. The notes document the progress your patient has made in each session and also track all relevant information about the patient. They assist the therapist in addressing recurring issues, accessing appropriate treatment for the patient, and adjusting documented information to track progress. In a nutshell, without consistent therapy notes, there is a risk of forgetting key issues or points during an appointment with a patient.
Understanding different types of therapy notes
All therapy notes are made for one goal and one goal only: to help improve the patient's progress. Therapy notes come in various types, and understanding the right one for the right scenario is equally vital when attending an appointment.
Different types exist to match the patient's preference at certain moments. Among all, SOAP, BIRP, and DAP are the most common ones. Each of them has their own way of offering a fast and consistent way to document each session, ensuring the notes are clear, efficient, and organized. Choosing the proper structure depends on your style. Here are the different types of notes and their use case:
SOAP notes (subjective, objective, assessment, plan):
Ideal for medical environments where the therapist is required to distinguish the client's subjective experience from the therapist's objective observation. SOAP notes are commonly used in hospitals, psychiatric treatment, and coordinated care systems because they offer a clinically complete and accurate format.
BIRP notes (behavior, intervention, response, plan):
DAP notes (data, assessment, plan):
They are primarily used in counseling and psychotherapy due to how simple it is and their effectiveness. DAP notes typically integrate subjective and objective data into a single section, which includes a professional assessment and a treatment plan. They are flexible, easy to write, and suitable for one, a family, or even a group counseling session.
Popular therapy note templates with examples
Standardized templates reduce ambiguity and help therapists document consistently. The most widely used are SOAP, BIRP, and DAP.
1. SOAP notes
SOAP stands for subjective, objective, assessment, and plan. It’s widely used across healthcare and mental health settings for structured clinical documentation.
Breakdown:
- Subjective: Patient’s concerns, feelings, and personal account of their condition. Document the client’s descriptions of why they sought therapy.
- Objective: Therapist’s observations, including appearance, behavior, and measurable data.
- Assessment: Therapist’s clinical impression or diagnosis.
- Plan: Interventions and steps to be taken to accomplish therapeutic objectives.
Example SOAP note (hypothetical case, demonstration only):
Subjective
- Presentation: Client arrived on time, reporting feeling "stuck" and apathetic.
- Chief complaint: Low mood, fatigue, and loss of interest in hobbies.
- Quote: "I don't feel like getting out of bed most mornings."
- Impairments: Difficulty completing activities of daily living, and neglects social contacts.
Objective
- Clinical assessment tool: Clinical interview.
- Observations: Flat affect, lacking eye contact, slouching posture.
- Risk assessment: No safety issues currently present.
Assessment
- Diagnosis: Symptoms characteristic of moderate major depressive disorder.
- Response to treatment so far: Limited engagement in prior behavioral activation exercises.
- Challenges: Negative thinking and avoidance behaviors persist.
Plan
- Homework: Maintain a mood diary and record one positive activity daily.
- Future session: Review mood diary, resume CBT exercises, and examine cognitive distortions.
- Treatment plan: Sessions are held weekly; refer to a psychiatrist if symptoms escalate.
2. BIRP notes
Breakdown:
- Behavior: The client’s actions, mood, and symptoms observed during the session.
- Intervention: Strategies or therapeutic approaches applied by the clinician.
- Response: Client’s reaction to interventions, including progress or resistance.
- Plan: Next Steps and Follow-up Actions
Example BIRP note (fictional case, for demonstration):
Behavior
- Symptoms: Client reported daily feelings of loneliness and lack of motivation.
- Quote: “I just go to places where there’s no one and sit there alone.”
- Observations: Exhibited tearfulness at times, avoided eye contact, and expressed hopelessness.
- Therapist reflection: Client shows signs of cognitive distortions (e.g., catastrophizing).
Intervention
- Approach: Cognitive-behavioral therapy (CBT).
-
Techniques used:
- Validated the client’s emotions.
- Introduced thought-tracking exercise.
- Encouraged reframing of negative automatic thoughts.
- Rationale: Build awareness of distorted thinking and encourage gradual behavioral activation.
Response
- Engagement: Client displayed reluctance but completed one reframing exercise during the session.
- Quote: “I don’t think I can change how I see things.”
- Progress: Limited, but the client acknowledged the possibility of alternative perspectives.
- Challenges: Low motivation and avoidance remain significant barriers.
Plan
- Homework: Complete thought-tracking sheet daily; attempt one social interaction this week.
- Future sessions: Review progress on thought-tracking and continue CBT strategies.
- Treatment plan: Ongoing weekly sessions, monitor for risk factors.
3. DAP notes
DAP (Data, Assessment, Plan) is a simplified format that maintains clinical rigor while saving time.
Template structure:
- D (Data): Objective and subjective session details.
- A (Assessment): Therapist’s clinical impressions.
- P (Plan): Future goals and interventions.
Example:
- D: Client shared difficulties sleeping and frequent worries about finances.
- A: Insomnia is likely linked to heightened stress; mild depressive symptoms noted.
- P: Teach relaxation breathing techniques; encourage sleep hygiene routine; follow-up on sleep diary next session.
My takeaway: Instead of manually creating these structures for every session, you can use Plaud NotePin to build a SOAP, BIRP, or DAP template once with a short prompt and then reuse it across sessions for consistency and speed.
Which is the right therapy note template for you?
The choice of the appropriate template depends on your therapeutic setting, the needs of clients, and documentation goals.
- SOAP notes are best suited for practitioners who need a structured, medically based format that insurance companies and multidisciplinary teams accept.
- BIRP notes are best suited in settings where progress is measured by observable behavior and therapeutic interventions in behavioral healthcare.
- DAP notes are ideal for therapists seeking a balance between structure and efficiency, making them a preferred choice for high caseloads.
Therapists don’t need to start and do everything by themselves. With access to Plaud Pro Plan, you can select from over 3,000 ready-made templates (e.g., progress notes, group therapy notes, intake summaries) and customize fields like goals, interventions, and treatment plans to match your practice.
How to write therapy notes with Plaud NotePin
Documenting therapy sessions doesn’t have to be time-consuming. With Plaud NotePin, therapists can capture conversations and generate structured notes effortlessly. NotePin combines a wearable recorder with AI-powered transcription and summarization to automate the process.
Step 1
Attach the Plaud NotePin to your clothing using the clip or magnetic pin. Its compact design makes it easy to wear discreetly during a session.
Step 2
Now, you press the button to begin recording. The microphone will capture every detail with clarity, while the device can run for up to 20 hours continuously on a single charge.
Step 3
When the session ends, stop the recording and open the Plaud App or web platform. Your audio syncs securely to your Plaud account, ready for transcription.
Step 4
Select from SOAP, BIRP, DAP, or other therapy note formats. Alternatively, use the photo-to-template feature to scan and digitize your own note format.
Step 5
Plaud’s AI transcribes the recording and structures it into your chosen format. Review, make minor edits if needed, and save. Notes are stored securely and can be reused across sessions.
Best practices for writing practical therapy notes
Even with templated formats, quality depends on the composition of notes. Based on the following best practices:
Be concise but comprehensive: Omit extraneous information but record important clinical information.
Be objective: Remain fact- and behavior-based and avoid personal observation.
Use professional terminology: Refrain from slang and regional idioms; write notes that are suitable for legal and clinical review.
Document interventions briefly: Summarize the session's key points and their relevance.
Ensure confidentiality: Refrain from documenting excessive personal details and uphold HIPAA and ethical guidelines.
Update regularly: Document entries as close to sessions as possible to foster accuracy.
Examples of therapy notes used for different use case situations
There are several styles of notes used by therapists, depending on the circumstances, such as DAP for normal counseling, SOAP for hospital settings, and BIRP for behavioral health. All styles of notes fit in with the therapist's goals, documentation protocol, and insurance requirements.
Example 1: Initial client session notes
S: Client complained of difficulty adjusting to recent job loss, presented with sadness and lack of energy.
O: Wept during session, flat affect, spotty eye contact.
A: Presentations characteristic of adjustment disorder with depressed mood.
P: Begin CBT model; see weekly sessions; provide psychoeducation on how to deal with the stress of job loss.
Example 2: Ongoing session progress notes
B: Client indicated a reduction in panic attacks from three times per week to weekly.
I: Therapist guided breathing and grounding skills.
R: Client demonstrated correct technique and reported relief during the session.
P: Proceed with exposure hierarchy; review frequency of panic attacks in two weeks.
Example 3: Crisis intervention notes
D: Client called an emergency session after experiencing suicidal ideation.
A: Risk level for suicidal thinking is high; protective factors present are strong family support and expressed desire to be safe.
P: Safety plan was instituted; referred to crisis hotline; follow-up in 48 hours.
These illustrations demonstrate how templates apply across contexts in a manner that is clear, consistent, and compliant.
Key takeaways
- Therapy notes serve as a record of clinical accountability, insurance compliance, and continuity of care.
- The most utilized structured templates are SOAP, BIRP, and DAP.
- Plaud NotePin uses automated note production with reusable custom and existing templates.
- Best practices include objectivity, clarity, and consistency.
- Real-world applications demonstrate how structured notes can be applied in any situation.
Conclusion
Beyond administrative records, therapy notes are the clinical history of client growth. By choosing official templates like SOAP, BIRP, or DAP, therapists ensure clarity, responsibility, and continuity of care. Electronic tools like Plaud NotePin facilitate this process, enabling professionals to produce correct, formal notes effectively without losing client interaction.
Accurate and precise documentation improves outcomes, supports ethical practice, and saves time. Therapy notes are a must-have resource for every therapist, whether documenting a live session, progress check-in, or crisis intervention.
Frequently asked questions (FAQ)
How long should therapy notes be?
Therapy notes must be concise but complete, one page or less. The goal is to record relevant clinical information without extraneous narrative.
Do I have to write notes after every session?
Yes. Professional and ethical guidelines require notes after every client contact to ensure accurate records and continuity of care.
How do I balance taking notes with staying engaged in the session?
Use structured templates and jot down important points in sessions. There are also tools like Plaud NotePin that allow recording and automatic note-taking so therapists can remain present with clients.
