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Progress note template — and how to pick your format

By Albert Wong, PhD, Clinical Psychologist

Strip away the acronyms and every good therapy progress note documents the same five things: how the client presented, what you did, how they responded, whether anyone is at risk, and what happens next. That is the whole game — it is what medical necessity means in documentation terms, and it is what an auditor, a covering clinician, or you-in-two-years will look for. SOAP, DAP, BIRP, and GIRP are simply four proven ways of arranging those five things.

This page gives you a format-agnostic template that carries all five, and an honest comparison of the four named formats so you can pick one and stop thinking about it.

The universal template

Plain text — paste into any EHR or document

THERAPY PROGRESS NOTE
(Format-agnostic — every element payers and auditors look for,
usable as-is or as a checklist against your preferred format.)

Client name: ____________________   Date of service: ____________
Start / end time: _______________   CPT code: ____________
Clinician: ______________________   Location / modality: ____________
Diagnosis: ______________________

1. PRESENTATION & REPORT
How the client presented and what they reported — symptoms, change
since last session, relevant events:

2. INTERVENTIONS
What you did this session, named specifically, and the treatment
plan goal(s) it addressed:

3. RESPONSE & PROGRESS
How the client responded to the interventions; progress toward
treatment plan goals (measure scores if administered):

4. RISK
Suicidal / homicidal ideation: denied / present.
If present: assessment, clinical reasoning, safety plan, and
actions taken:

5. PLAN
Next session focus, homework assigned, referrals or coordination,
any treatment plan changes, and next appointment:

Clinician signature / credentials: ____________  Date signed: ________

A filled example

"Jamie A." is a fictional client — every detail below is invented and deliberately generic. Never copy identifying details from real charts into templates or samples.

Fictional example — for structure, not content

THERAPY PROGRESS NOTE — FILLED EXAMPLE (fictional client)

Client name: Jamie A. (fictional)   Date of service: 03/12/2026
Start / end time: 15:00 - 15:50     CPT code: 90834
Clinician: A. Beaumont, PsyD        Location / modality: Office, in person
Diagnosis: Adjustment disorder with anxiety (F43.22)

1. PRESENTATION & REPORT
Jamie arrived on time, engaged and appropriately groomed. Reported a
"middle of the road" week: workplace transition stress continues but
described using the planning routine on most workdays. Rated overall
stress 5/10, down from 7/10 at intake. Sleep and appetite stable.

2. INTERVENTIONS
Continued CBT for adjustment-related anxiety (treatment plan goal 1).
Reviewed the daily planning routine and guided cognitive
restructuring of one recurring catastrophic prediction about the new
role. Assigned and rehearsed a brief pre-meeting grounding exercise.

3. RESPONSE & PROGRESS
Jamie generated a balanced alternative thought with minimal prompting
and reported the reframe "took the temperature down." Practiced the
grounding exercise in session and demonstrated correct use.
Progress toward goal 1: self-rated stress trending down for the
third consecutive week.

4. RISK
Denied suicidal and homicidal ideation. No risk indicators observed.

5. PLAN
Continue weekly individual CBT. Homework: use grounding exercise
before at least two meetings; log outcomes. Next session: review
log; begin relapse-prevention planning if gains hold. No treatment
plan changes at this time.
Next appointment: 03/19/2026, 15:00.

Clinician signature / credentials: A. Beaumont, PsyD   Date signed: 03/12/2026

SOAP vs DAP vs BIRP vs GIRP

Format	Sections	Organizing idea	Strongest fit
SOAP	Subjective · Objective · Assessment · Plan	Separate what was reported from what was observed	Integrated care and anywhere medical providers share the chart — every discipline reads SOAP natively
DAP	Data · Assessment · Plan	One factual record, then interpretation	Outpatient private practice — fastest to write; the S/O split rarely earns its keep in talk therapy
BIRP	Behavior · Intervention · Response · Plan	Center the clinician's interventions and their effect	Agency and community mental health, where documentation must show actively delivered treatment
GIRP	Goal · Intervention · Response · Plan	Open every note with the treatment plan goal it served	Settings that audit for goal linkage — or clinicians whose notes drift from the plan

Two honest observations. First, the differences are smaller than the acronyms suggest — all four converge on the same five elements, and a well-written note in any of them passes the same audit. Second, consistency beats optimization: pick the one that matches your setting, use it for every note, and spend the reclaimed deliberation on the content. Full templates and filled examples: SOAP, DAP, BIRP, GIRP.

Habits that make any format work

Write the same day. The note you write at 5 p.m. is more accurate and three times faster than the one you reconstruct on Friday.
Let numbers carry progress. A periodic measure score turns "client is improving" into data — the free PHQ-9 / GAD-7 scorer makes it a thirty-second habit.
Match the note to the bill. Documented time should support the CPT code — the CPT code picker covers the psychotherapy codes and their time thresholds, and the billing glossary decodes the rest of the vocabulary.
State risk every time. "Denied SI/HI" is four words; its absence is the first thing a reviewer notices.

And if the blank page is the real enemy: Practice Harbor's note templates support all four formats, with AI drafting that writes the first draft from your session for you to review, edit, and sign.

Common questions

Do insurance companies require a specific progress note format?

No — we know of no payer that mandates SOAP, DAP, BIRP, or GIRP by name. What payers require is documentation of medical necessity: that a covered service was delivered on a documented date for an appropriate length of time, what interventions you used, how the client responded, progress toward treatment goals, and the plan going forward. Any of the four formats carries that content when written well; none of them saves a note that omits it. Agencies and specific contracts can impose a house format, so check yours.

What must every progress note include, regardless of format?

The reliable core: client identity and date of service; start and end time (or duration) supporting the billed CPT code; the diagnosis being treated; the interventions you used, specifically named; the client’s response; progress toward treatment plan goals; a risk statement — even routine denial of suicidal and homicidal ideation; the plan going forward; and your signature with credentials and the signing date. Audit findings are overwhelmingly about missing elements from this list, not about formatting.

What is the difference between progress notes and psychotherapy notes?

Under HIPAA these are distinct things. Progress notes are the official medical record — they document treatment, support billing, and are what payers, other providers, and (in most circumstances) the client can see. "Psychotherapy notes" is HIPAA’s term for a therapist’s separate process notes — your analyses, hypotheses, and session impressions — which receive extra protection only if kept separate from the medical record. Practical rule: everything billing and continuity of care needs goes in the progress note; your private working thoughts, if you keep them, live separately and are never required.

How soon after a session should I write the note?

The same day is the professional norm and the practical answer: accuracy decays fast, and unsigned notes compound into a backlog that is itself a compliance problem. Some agencies and payer contracts set explicit deadlines (24, 48, or 72 hours are common in agency policy); absent one, treat "before the next client day starts" as your own. A template you fill in the last minutes of the hour beats a beautiful note written on Sunday.

Can AI write my progress notes?

AI can draft them; it cannot be responsible for them. A drafting tool that turns your session into a structured first draft genuinely saves time, but the clinical judgment — what the intervention was, what the response means, the risk assessment, the diagnosis — is yours, and the signature that attests to accuracy is yours. Review every draft as skeptically as you would a trainee’s note, correct what is wrong, and only then sign. Also confirm any tool you use will sign a Business Associate Agreement before session content touches it.

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This template and guidance are general clinical-documentation education, not legal advice. Documentation requirements vary by state, license type, agency policy, and payer contract — check yours.

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