The 3 Common Clinical Notes Used in Behavioral Health and Differences Between Them

Behavioral health practice highly relies on effective documentation for diagnostic decision-making. Efficiency clinical note-taking is important for accurate documentation, which is to ensure tracking progress and better care delivery for clients. 

In behavioral health, there are three common clinical notes used for therapy. A better understanding of these clinical notes and their differences is crucial. In this blog post, we have shared the 3 common clinical notes used for behavioral health therapy and the differences between them.

What is Clinical Notes in Behavioral Health?

Clinical notes in behavioral health record the specific information found during encounters with clients, like mental health assessments, treatment plans, and progress.

The clinical observations, diagnoses, client’ reported symptoms, therapy goals, and results of interventions are all recorded on the clinical notes. 

In behavioral health, those are found to be very important for recording conditions like 

• Depression 
• Anxiety 
• PTSD
• Substance use disorders. 

They give providers a holistic overview of the client’s mental health journey, wherein they can estimate the effectiveness of treatment and adjust their strategies if necessary. 

Accurate and well-documented clinical notes also provide care continuity, inter-provider communication, and legal/insurance requirements; therefore, they essentially encourage both clinical and administrative excellence in patient care.

Related: How EHR Automation Tools Can Improve Clinical Notes for Behavioral Health

3 Common Clinical Notes Use for Behavioral Health Therapy

There are many types of clinical notes like psychiatry progress notes, group notes, and therapy progress notes, that are being used for behavioral health therapy. 

However, these three are the commonly used clinical notes in behavioral health.

1. SOAP (Subjective, Objective, Assessment, Plan) Notes

The SOAP note is the standardized method of recording client encounters, mainly in mental and behavioral health therapy settings. In the term SOAP, the initials represent the core parts of the process: 

• Subjective
• Objective
• Assessment
• Plan.

Subjective section

It captures the personal experiences of the client, concerns, and self-reported details. It can address the thoughts, feelings, symptoms, or whatever trouble the client is facing personally. 

It is a tool through which the client can voice his feelings and tell the therapist whatever he thinks of his condition.

Objective section

The client is concerned with observable, measurable data observed by the therapist during the session. For example, 

• Changes in behavior 
• Emotional manifestations 
• Somatic complaints 
• Laboratory 
• Diagnostic test results 

are observable, measurable data. The information obtained here must be verifiable and factual.

Assessment section

The therapist provides a clinical impression that is known both by subjective and objective information. Progress analysis, identification of problems, or an assessment of the client’s response to treatment can also be part of this step. 

Such assessment sections usually include both diagnosis and re-diagnosis of the conditions being treated and considerations for a change in treatment if issues are pertinent to modification.

Plan section

Finally, the plan section describes what the therapist is going to do to resolve the client’s problems. This could be some intervention or technique therapists intend to apply during therapy or modifications of the current treatment plan based on session findings. 

Changes to the course of therapy will be referenced here.

It will eventually enable therapists to plot sessions consistently over time, track progress accurately, and assist in communication with other healthcare providers. All important care aspects of the client will also be discussed systematically and comprehensively.

Related: How Generative AI In Clinical Notes Transforms Medical Documentation

2. BIRP (Behavior, Intervention, Response, Plan) Notes

This is one of the common documentation forms in mental health environments. BIRP stands for the terms: 

• Behavior
• Intervention
• Response
• Plan. 

Below, it gives a structured concise way in which therapists may provide critical information in a comprehensive form. 

The same can be done not only in tracking the systemic trend of a client’s therapeutic journey but also in communicating and cooperating among healthcare providers.

Behavior

The behavior section of behavior therapy essentially monitors the documented behaviors, emotions, or symptoms as reported by the client in the session. Such a thing would involve observable actions and documenting self-reported feelings. 

For example, entries might note, “The client looked agitated and anxious,” or “The client stated feelings of hopelessness and a loss of interest.” 

Ultimately, this leads to the fact that the behaviors observed allow therapists to search for and track patterns and trends within the client’s overall status of mental health over time.

Intervention

That is why the therapist specifies the kind of techniques, therapies of interventions used to address the client in the session. The interventions could be cognitive-behavioral therapy, mindfulness, or some kind of relaxing intervention. 

For example, the methods could be “that of guided imagery for stress reduction, cognitive restructuring to challenge negative thought patterns.” 

The goal is to document the therapeutic strategies used to make it easier to determine what will work best for clients. A study shows that 67% of the clients will improve in structured therapeutic interventions if applied consistently.

Response

The response section describes the way the client has reacted to the interventions that were brought in the session. In this regard, it is a document on how the client would be responding either emotionally or behaviorally. 

For example, a note might read as “Client reported feeling calmer after practicing deep breathing exercises” or “client reframe negative thoughts more effectively.” 

This serves as a means of determining how effective a session might be. Furthermore, It empowers the therapist to make future adjustments for the same interventions.

Plan

The treatment plan section details the treatment steps for the client. This can be as simple as setting specific goals, giving homework, or planning for some form of intervention in the future. 

For instance, the therapist would write, “Client will practice mindful living exercises at home” or “Discuss how stress affects the daily tasks in the next session.”

Goal setting should be client-centered as studies indicate that 85 percent of patients who enter therapy report that they were better engaged in their treatment when they were included in composing their treatment plans.

The BIRP note format may thus be used by therapists ensuring documentation is accurate, very detailed, and longitudinal in the process. 

This would essentially maintain continuity of care by different providers while strengthening the therapeutic process in an organized and systematic manner through ongoing progress tracking.

3. DAP (Data, Assessment, Plan) Notes

DAP stands for 

• Data
• Assessment
• Plan. 

A template of clinical documentation practice, this is quite frequently available in mental health and behavioral therapy. 

A DAP note is not a traditional progress note; it takes on the form of a client-centered approach because it focuses on the aspect of the client’s progress or goal and the therapy journey undertaken.

Data

Therapists document as much relevant information about the experiences, behaviors, and symptoms of clients as follows: this can be self-report from the client and observations from the therapist during the session. 

The collection of detailed and accurate data gives therapists an understanding of what is happening to or with the clients in terms of their mental and emotional state. This is a critical section in capturing changes in symptoms and changes in client behavior over time.

Assessment

This section involves processing all the data gathered and how well the client is doing to meet the treatment goals. The therapists observe some patterns, and changes in symptoms, and assess the interventions of this treatment, their success, and shortcomings. 

Furthermore, It highlights obstructions that might impede the client’s progression, such as stressors from life, repetitive occurrences of symptoms, or lack of commitment toward treatment. 

With appropriate assessment, therapists can make good adjustments in their approach to help determine whether the treatment is on the right track or if it needs modification. 

One study published in the Journal of Clinical Psychology shows that about 40% of clients require adjusted interventions during therapy because of different rates of progress.

Plan

Finally, the Plan section is where the therapist sums up the strategy of the treatment. In that section, he outlines future goals in therapy, proposes needed interventions, and upon summary adjusts treatment strategies based on the assessment he has gathered. 

Thereby, it gives direction to the therapist and the client ensuring there is no loose activity but orientation in therapy.

A clear plan as such ensures the continuation of therapy. This way, any progress in the treatment course is easy to trace from time to time.

Generally, DAP notes are a structured yet flexible approach to documentation that is bound to the journey of an individual and the outcome of therapy. 

It allows the gathering of information, provides a more precise assessment of where a client may be progressing, and clearly outlines treatment plans. 

DAP notes improve the benefits associated with therapy besides encouraging care continuity between therapists and clients at large. 

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