TherapyNotes offers three additional Progress Note formats—SOAP, DAP, and BIRP—so clinicians can choose the template that best fits their documentation style, clinical needs, and practice standards. Each template provides a structured approach to session documentation, helping clinicians capture essential details while maintaining efficiency and compliance.
As a Practice or Clinical Administrator, you have the option to narrow down which templates are available to your clinical staff, ensuring documentation remains consistent with your organization’s standards and insurance guidelines.
SOAP Progress Note
SOAP stands for Subjective, Objective, Assessment, and Plan. This format is widely used in healthcare and balances client-reported information, clinical observations, and treatment planning.
| Fields Included: |
| Diagnosis Fields (with ICD-10) |
| Subjective: The client’s perspective, symptoms, or concerns in their own words. |
| Objective: Observable facts, clinician’s findings, test results. |
| Treatment Planning Progress |
| Assessment: Clinical impressions, progress, or diagnoses based on the subjective and objective data. |
| Plan: Next steps that include treatment interventions goals, and follow-up. |
| Recommendations, Frequency of Treatment, and Signature |
This note is for:
- Practices that require comprehensive medical-style records.
- Clinicians who collaborate with other healthcare providers.
- Settings where insurers or regulators expect detailed documentation.
When to use it:
- When a detailed account of a session is needed.
- When documenting both medical and psychological components.
- When working in multi-disciplinary environments.
Key benefits:
- Provides a complete record for complex cases.
- Standard structure that is familiar across healthcare disciplines.
- Balances client report, clinical judgment, and planning.
DAP Progress Note
DAP stands for Data, Assessment, and Plan. This format is streamlined and focuses on capturing the most essential elements of the session.
| Fields Included: |
| Diagnosis Fields (with ICD-10) |
| Data: Factual information, client statements, and observations. |
| Treatment Planning Progress |
| Assessment: Clinical interpretation, evaluation of progress, and diagnosis if applicable. |
| Plan: Outline of next steps, interventions, and goals. |
| Recommendations, Frequency of Treatment, and Signature |
This note is for:
- Counselors and therapists who need efficient documentation.
- Clinicians who prioritize progress tracking and treatment planning.
- Practices that want concise notes while maintaining clinical accuracy.
When to use it:
- When time-efficient documentation is important.
- When a clear, straightforward structure is preferred.
- When working across individual, group, or family therapy settings.
Key benefits:
- Faster to complete than SOAP format.
- Customizable to different therapy types.
- Provides clarity while remaining concise.
BIRP Progress Note
BIRP stands for Behavior, Intervention, Response, and Plan. This format highlights therapeutic interventions and client responses, making it well suited for mental health treatment.
| Fields Included: |
| Diagnosis Fields (with ICD-10) |
| Behavior: Observable client actions, statements, and emotions. |
| Intervention: Techniques or strategies used during the session. |
| Response: Client’s reaction to the interventions, including engagement and progress. |
| Treatment Planning Progress |
| Plan: Next steps, follow-up actions, or treatment goals. |
| Recommendations, Frequency of Treatment, and Signature |
This note is for:
- Clinicians focused on documenting therapeutic techniques and outcomes.
- Mental health practices that emphasize accountability in treatment.
- Settings where showing the impact of interventions is a priority.
When to use it:
- When tracking the connection between interventions and outcomes is important.
- When demonstrating treatment effectiveness for clinical or administrative purposes.
- When structured documentation of interventions is required.
Key benefits:
- Focuses on clinical techniques and client outcomes.
- Standardized format for documenting effectiveness.
- Streamlined for behavioral health settings.
To learn more about using the pre-built and custom templates, read Writing Notes with Progress Note Templates.
Access the Note Templates Library
Click Library > Note Templates tab
The Note Templates Library offers four pre-built note templates to use as-is or customize:
- BIRP Progress Note
- DAP Progress Note
- SOAP Progress Note
- TherapyNotes Progress Note (default)
You can Preview, Edit, or Copy and Customize any template.
(A) Status Filter: The template status can be filtered by Show All, Active, Inactive, and Draft to find the most relevant option.
(B) + Create Template: This allows you to start a new template from scratch or from an existing one.
(C) Edit or Copy: Click the Edit icon to change the Note Display Title, Description, or Status (Active/Inactive).
- Active templates appear in the Template Selector when creating a note.
- Inactive templates are hidden from clinicians.
Click the Copy icon to duplicate a template. The copied template opens in the Template Builder, where you can edit and customize it.
Best Practices
- Audit regularly: Review which templates are actually used in your practice and deactivate unused ones.
- Review and update: Look at templates periodically to ensure they match your practice’s documentation needs
- Train clinicians: Let staff know when a template has been updated or renamed.
- Use descriptive names: So clinicians can quickly identify the right format.