You finish a session where your client disclosed new trauma content, agreed to try exposure homework, and asked about changing their medication. You have eight minutes to write a note before your next client arrives; a note that captures clinical reasoning, demonstrates medical necessity, documents risk, and holds up if audited.
Behavioral health notes aren’t just paperwork. They’re your legal protection, your clinical memory, and increasingly, a document your clients will read. However, with the short amount of time available, most therapists struggle immensely with writing notes that satisfy regulators and support quality care.
This guide covers what goes into compliant behavioral health notes, which formats work best, and how to write efficiently without cutting corners.
TL;DR
- Behavioral health notes serve three core functions: they document care, support continuity across providers, and establish medical necessity for reimbursement.
- Progress notes are not the same as psychotherapy notes—clients have a legal right to access progress notes, but your private process reflections stay confidential.
- SOAP, DAP, and BIRP formats give you flexible structures to stay organized, meet payer expectations, and write faster.
- Every note must include session details, diagnosis rationale, interventions tied to goals, observable client response, and current risk level.
- AI scribes like Supanote can save you hours each week while capturing the clinical nuance behavioral health work demands.
What Are Behavioral Health Notes?
Behavioral health notes document the care you provide, the progress your clients make, and the risks you assess along the way. They're your clinical memory, your legal record, and your proof that the work you do is medically necessary.
Every note you write serves three functions:
- Captures what happened in session so you can pick up where you left off next time.
- Creates a defensible record if your documentation is ever reviewed by a payer, board, or court.
- Explains medical necessity for why the treatment you’re providing to your client is needed now.
Behavioral health notes also support effective handovers and collaborative care when you’re working with other providers and support professionals.
Behavioral Health Progress Notes vs. Process Notes
In any discussion about behavioral health notes, it’s important to make the distinction between progress notes and process notes.
Progress notes document the services you rendered (what you did, why, and how the client responded). Your client usually has a legal right to access these under HIPAA's Right of Access rule, and many mental health EHRs now push them to patient portals automatically.
Process notes (also sometimes called psychotherapy notes) are your private reflections. These might include transference dynamics, your clinical hypotheses, or impressions you wouldn't share in session. Under the HIPAA Privacy Rule, psychotherapy notes are not part of the legal health record, and can't be disclosed without special authorization.
Throughout this article, when we mention behavioral health notes, we’re talking about progress notes, not process notes.
Types of Behavioral Health Notes
Obviously, there’s more to behavioral health notes than the standard progress note you write after each session. Below are some of the other types of behavioral health documentation commonly completed alongside progress notes, along with tips for completing them well.
Intake and Assessment
Your intake note (sometimes called an intake assessment) lays the foundation for everything that follows. It should include the presenting problem, relevant history, and any relevant assessments (such as a mental status exam or biopsychosocial assessment).
Document your diagnosis rationale clearly in behavioral health intake notes. If you're holding off on a final diagnosis, explain why and list your differential. Include baseline measures like the PHQ-9 or GAD-7 so you have a starting point to measure progress. Screen for risk and document any immediate safety needs or protective factors.
Treatment Plan
A good treatment plan defines what you're working on and how you'll know when you get there. Start with problem statements tied to functional impairment, then write measurable goals with target dates.
In the treatment plan, list the interventions you'll use, the frequency of sessions, and who's responsible for what. Set a cadence for reviewing and updating the plan, usually every 90 days (or sooner if the client's needs change).
Discharge Summary
When treatment ends or the client transfers to another provider, a discharge summary that captures the course of care, progress toward goals, and current risk level should be completed. Where relevant, a discharge summary also includes details about medications, aftercare recommendations, and any referrals you've made.
The discharge note is the last piece of the clinical story in behavioral health care. Make it clear enough that the next provider can pick up where you left off, and specific enough that the client knows exactly what to do next.
Formats for Behavioral Health Notes
Therapists can choose from a variety of behavioral health note formats. SOAP, DAP, and BIRP are the most popular. However, some providers create their own personalized template or prefer unstructured, narrative-style notes.
For ease of reference, here’s an overview of the structures of SOAP, DAP, and BIRP notes.
SOAP
SOAP is the classic behavioral health note format:
- Subjective captures what the client tells you (use direct quotes when they add clarity).
- Objective includes your observations, mental status findings, and any scales or scores you collected.
- Assessment is where you interpret the data. What's your clinical impression? How is the client progressing toward goals? What's the current risk level?
- Plan documents what you're doing next—interventions, homework, frequency, and any referrals or follow-up needed.
DAP
DAP condenses subjective and objective into a single Data section. This works well when your observations and the client's report overlap, or when you want to move quickly through the note.
Assessment covers your clinical judgment, diagnosis status, and interpretation of progress. Plan outlines next steps, responsibilities, and any changes to treatment.
BIRP
The features of a BIRP note follow this structure:
- Behavior covers what you observed about the client during the session (mainly objective, not just what you inferred.
- Intervention names what treatment you administered and why you chose it.
- Response captures how the client reacted and what progress you observed.
- Plan covers follow-up actions and homework.
BIRP notes work especially well for behavioral and skills-based approaches where you want to highlight the client's observable change.
Choosing a Format
In most cases, clinicians can choose the behavioral health note format that applies best to the client’s situation. However, seeing as note formats can largely be used interchangeably, many therapists find it easiest to simply pick the format your payers expect and your team already uses.
The format matters less than the content. Use structure to keep your notes focused, but don't let the template distract you from capturing what actually happened in the room.
Behavioral Health Note Comparison Table
SOAP | DAP | BIRP | |
|---|---|---|---|
Structure | Four distinct sections (Subjective, Objective, Assessment, Plan). | Three sections combining subjective/objective data. | Four sections emphasizing behavioral observation. |
Primary focus | Medical model. Separates client report from clinical observation. | Streamlined efficiency, with lless categorical separation. | Behavioral specificity and intervention response. |
Best for | Medical settings and psychiatry, when vitals/labs matter. Payers expecting traditional medical documentation. | Solo practitioners wanting efficiency. Integrated behavioral health in primary care. | Behavioral health specialists. ABA providers, when tracking specific interventions and responses. |
Client report | Isolated in Subjective section (often uses direct quotes). | Combined with observations in Data section. | Integrated into Behavior section as a verbal report. |
Clinical thinking | Distinct Assessment section for diagnosis, formulation, progress. | Assessment section combines meaning-making with clinical judgment. | Embedded in Response section, detailing how the client reacted to intervention. |
Strengths | Clear separation of fact from interpretation. Widely recognized format. | Faster to write due to intuitive flow. Reduces redundancy. | Excellent for demonstrating intervention effectiveness. Behavioral language reduces subjectivity. |
Limitations | Can feel rigid. S and O sections sometimes overlap. | Less structure may lead to vague content without discipline. | Requires precise behavioral language. May feel constraining for insight-oriented work. |
Documentation time | Moderate. Structure helps, but completing the four sections take time. | Fastest of the three formats. | Moderate. Behavioral specificity requires precision. |
Best for which modality | Medication management, crisis work, integrated care, psychiatry. | Brief solution-focused therapy, coaching, general outpatient therapy. | CBT, DBT, ABA, any evidence-based practice tracking specific techniques. |
Below are the key components that must be covered in compliant behavioral health notes. These details are vital for medicolegal protection and meeting payer requirements.
Session Details
Every note needs the basics:
- Date
- Start and stop times
- Duration
- Location
- Attendee(s)
- Signature
If you're providing telehealth, note that explicitly. Include the service type, CPT code, and any modifiers required by your setting.
Medical Necessity and Goals
Include these components to demonstrate medical necessity in behavioral health notes:
- State the diagnosis and explain why treatment is necessary now.
- Link your interventions to functional impairment and treatment goals.
- Show progress or identify barriers every session.
Medical necessity is the thread that runs through every note. If an auditor can't see why this session happened this week, you've left out something important.
Interventions and Response
Here are the key points for capturing interventions and treatment response in behavioral health documentation:
- Name your modality clearly. "CBT cognitive restructuring" is better than "discussed negative thoughts."
- Describe how you delivered the intervention, not just the topic you covered.
- Capture the client's response with observable language. Did they practice the skill in session? Could they demonstrate it independently or did they need prompting? Did their affect shift, their reported distress decrease, or their understanding deepen?
Risk and Safety
Effectively documenting risk and safety measures is vital for medicolegal protection in your notes. These are the main points to include:
- Screen for suicidal ideation, homicidal ideation, abuse, and psychosis as clinically indicated.
- Document protective factors and any means of counseling you provided.
- If you updated a safety plan or consulted with a supervisor or colleague, record that too.
Risk documentation doesn't have to be long, but it must be current and objective.
Modality-Specific Behavioral Health Documentation
Different treatment modalities require different documentation elements. Match your behavioral health note content to what matters most in the intervention you're providing.
CBT notes identify the automatic thoughts targeted, cognitive distortions addressed, and behavioral activation or exposure steps completed. Document homework assigned and what the client reports about adherence. Capture thought records or behavioral experiments when they're part of the session work.
DBT documentation specifies which skills you targeted: mindfulness, distress tolerance, emotion regulation, or interpersonal effectiveness. Note diary card highlights and any coaching contacts between sessions. Record commitment strategies, chain analysis details, and progress toward behavioral targets.
EMDR notes include the target memory, baseline, and closing SUD and VoC ratings, which phase of the protocol you're in, the type of bilateral stimulation used, and how the client responded. Document stabilization techniques and how you achieved closure at session end.
Motivational interviewing and brief therapy documentation captures change talk versus sustain talk, specific examples of each, decisional balance work, importance and confidence ratings on scaling questions, and the concrete next steps the client agreed to take.
Family, couples, and group therapy notes document who attended, interaction patterns observed, systemic formulations you're working from, and specific interventions used. Remind yourself of confidentiality considerations. In group notes, document individual progress toward that person's goals without including others' protected health information.
Psychiatry and medication management notes require mental status exam findings, vital signs when available, medication side effects, adherence patterns, any medication changes with clinical rationale and client input, relevant lab results, PDMP checks, and risk counseling provided. Specify follow-up interval and what triggers earlier contact.
Examples and Mini-Templates for Behavioral Health Notes
SOAP Example (Depression, Individual Therapy)
S: "Felt down 5 of 7 days; got out of bed by 10 a.m. twice this week. Haven't called my sister back."
O: Affect constricted, limited eye contact. PHQ-9 score 16, down from 18 two weeks ago. Arrived on time, grooming appropriate.
A: Moderate major depressive disorder. Engaging in behavioral activation with partial progress. Negative cognitions persist, especially related to self-worth. Denied suicidal ideation. Protective factors stable.
P: Increase behavioral activation to three activities this week. Introduce cognitive restructuring targeting "I am a failure" thought. Follow up in one week.
DAP Example (Anxiety, CBT)
D: Client reported three panic episodes this week, down from five last week. Used box breathing twice; heart rate decreased from 120 to 85 bpm per smartwatch. Anticipatory anxiety remains high before social events.
A: Panic disorder with agoraphobia. Skills helping to manage acute symptoms. Anticipatory anxiety and avoidance patterns persist. No safety concerns.
P: Conducted in-session interoceptive exposure (spin in chair, breathe through straw). Assigned daily two-times exposure practice and trigger log. Follow-up in one week.
BIRP Example (DBT, Skills Group)
B: Participated in mindfulness exercise, minimal eye contact with group members. Endorsed urges to self-harm at 3/10 intensity. Shared example of using opposite action over the weekend.
I: Taught TIP skill (temperature, intense exercise, paced breathing, paired muscle relaxation). Problem-solved barriers to using opposite action when urges increase.
R: Practiced TIP using ice and paced breathing. Reported decreased tension. Demonstrated understanding of when to use TIP versus opposite action.
P: Diary card review next week. Instructed to contact coach if urges exceed 6/10. Continue daily mindfulness and opposite action practice.
Using Technology to Reduce Note-Taking Time
Writing detailed, compliant behavioral health notes is an unavoidable part of practice. But there are no benefits to spending longer than necessary on documentation.
Fortunately, well-designed EHRs and AI scribes can reduce note-taking time while still maintaining quality and compliance.
EHRs
Most EHRs include templates for common behavioral health note types that can help speed up documentation. Often, EHRs can also pre-populate some of the required information for a note, such as date, client demographics, and even diagnostic details.
More advanced EHR features to save time on behavioral health notes include smart phrases for elements you commonly repeat (eg, consent language, risk screens, or plan components). Some also support the mapping og treatment plan objectives to progress note templates, so goals auto-populate.
AI Scribes
AI medical scribes can save you hours each week by listening to your session and drafting a structured note in real time. The best ones don't just transcribe—they understand clinical language, track risk, and map interventions to treatment goals.
Not all AI scribes handle behavioral health notes well. Generic medical scribes often miss the nuance of therapy notes, such as affect, process, and relational dynamics. Supanote is purpose-built for behavioral health, trained to capture what matters in therapy sessions and generate notes that meet compliance standards without losing your clinical voice.
Common Behavioral Health Note Mistakes
Here are some common mistakes in behavioral health notes and quick fixes.
Vague Content
Problem - A vague statement like "Discussed coping skills" doesn't tell you what happened. "Taught diaphragmatic breathing; client practiced three times in session and reported feeling calmer" does.
Fix - Replace vague verbs (discussed, explored, processed )with specific actions and observable outcomes.
Missing Medical Necessity
Problem - If your note doesn't explain why a session was needed, an auditor will question it. State the functional impairment clearly and link every intervention to a current treatment goal.
Fix - Medical necessity isn't assumed. Be sure to show it in every note.
Risk Gaps
Problem - Silence on risk looks like you didn't think about it. When you don't formally assess for risk, don’t skip risk documentation.
Fix - If the clinical picture doesn't warrant a formal risk assessment, say so. If you did screen and the result was negative, write that down.
Copy-Paste Drift
Problem - Copy-paste saves time, but it can also lead to notes that don't reflect what actually happened. In short, if your notes from three weeks ago look identical to your notes today, something's wrong.
Fix - Refresh your observations each session. Update scores, risk levels, and progress toward goals regularly.
Code-Specific "Audit-Proof" Note Checklist
Accurate coding helps you get paid fairly for the care you deliver and ensures your behavioral health notes hold up in an audit. Use this table as a mini documentation checklist for common behavioral health codes.
Code | Checklist |
|---|---|
90837 60-Minute Psychotherapy | Document total session time, start and stop times, and medical necessity for the extended duration. Show active interventions throughout (teaching, practicing, processing) not just discussion. |
90785 Interactive Complexity | Note the qualifying factor: involvement of a third party, communication barriers, maladaptive behavioral patterns that complicate care. Explain how it impacted the session and required additional clinical effort. |
Document the crisis nature clearly (immediate risk, acute distress, urgent need for intervention). Include your risk assessment, the crisis intervention steps you took, and start and stop times for each code. | |
Define the identified patient. When the client isn't present, link the session to the treatment plan and document family-based treatment goals. Make it clear how the session supports the client's care. | |
Document distinct psychotherapy content and time, separate from medication management. Show that you provided both services in the same session and that each was medically necessary. | |
90853 Group Psychotherapy | Document each member's individualized response and progress toward their own goals. Avoid including other members' protected health information in any one person's note. |
Final Thoughts: Behavioral Health Notes
Behavioral health notes are your clinical record, your legal defense, and your roadmap for ongoing care. They don't have to be perfect, but they do have to be clear, focused, and tied to goals.
Capture what you did, why it mattered, how the client responded, and what comes next. Document risk every time. Use a structure that works for you and your payers, and write notes assuming your client will read them.
If documentation is eating into your clinical time, consider using a purpose-built AI scribe like Supanote. It listens, learns, and drafts notes that sound like you, so you can spend less time writing and more time doing the work that matters.
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Get it Now!FAQs About Behavioral Health Notes
How long should a behavioral health note be?
Long enough to demonstrate clinical reasoning and medical necessity. Most progress notes fit into six to twelve concise sentences. If you're writing more than that, check whether you're mixing process reflections into the progress note (those belong in psychotherapy notes).
How soon should I write my notes after a session?
Same day is best. Within 24 hours is essential for sessions involving risk assessment, medication changes, or complex clinical decisions. The longer you wait, the harder it is to remember the details required to produce a high-quality, compliant behavioral health note.
Can clients see their behavioral health notes?
Yes, with limited exceptions. Clients have a legal right to access progress notes under HIPAA's Right of Access rule. Psychotherapy notes (your separate, private reflections) are excluded from this requirement and stay confidential unless you provide special written authorization.
How long do I need to keep behavioral health notes?
Follow your state law, payer contracts, and licensing board requirements. Most states require seven to ten years of retention for adult records, and longer for minors (often until the age of majority plus the adult retention period).
Do I need to document medical necessity in every note?
Yes. Every behavioral health progress note should explain why this session was clinically necessary at that specific point in treatment. Link your interventions to the client's functional impairment and treatment goals. If an auditor can't see the medical necessity, your claim may be denied.
Can I use templates for behavioral health notes?
Yes, but use them thoughtfully. Behavioral health note templates help you stay organized and write faster, but they also create the risk of copy-paste errors and generic notes that don't reflect what actually happened. Customize every note to the session and update key details each time.
What happens if I forget to document something important?
Write a late entry or addendum to your behavioral health note as soon as you realize the omission. Note the current date, explain what you're adding, and clarify why you're adding it now. Be honest and straightforward. Late entries are common and legally defensible as long as they're clearly marked.
How do I write notes that are both client-friendly and clinically useful?
Behavioral health notes should use objective, respectful language that you'd be comfortable with your client reading. Avoid jargon, stigmatizing terms, and speculation about third parties. Keep your clinical reasoning clear and your interventions specific. Move reflective or process content into psychotherapy notes, where it stays confidential and protected.