The following is a current list of Note Types available for those with a Documentation Automation plan.
For Therapists
SOAP (Subjective, Objective, Assessment, Plan): This is one of the most common types of progress notes. It organizes the session details into four categories: the client's subjective experience, objective observations, the therapist’s assessment, and the treatment plan.
DAP (Data, Assessment, Plan): A simplified note format that focuses on capturing session data, the therapist’s assessment, and the next steps in the treatment plan.
BIRP (Behavior, Intervention, Response, Plan): This note type emphasizes the client's behavior during the session, the interventions used by the therapist, the client’s response, and the treatment plan moving forward.
GIRP (Goal, Intervention, Response, Plan): Similar to BIRP, but with a focus on tracking specific goals, the interventions used to meet those goals, the client’s response, and the plan for future sessions.
EMDR (Eye Movement Desensitization and Reprocessing): A specialized note type for documenting sessions that use EMDR therapy. It includes details on the client's responses and progress in processing traumatic memories.
Case Management: A note type focused on managing client resources and services. It documents administrative tasks, coordination of care, and collaboration with other providers or agencies on behalf of the client.
Intake: The initial session or assessment when a client first begins therapy. This note covers background information, presenting issues, and the therapist's initial assessment, setting the stage for future treatment.
SIRP (Situation, Intervention, Response, Plan): This note type is used to document crisis or significant situations during a session. It records the presenting situation, interventions used, the client’s response, and the plan moving forward.
PIRP (Problem, Intervention, Response, Plan): Similar to BIRP and GIRP, this note type focuses on a specific problem, the interventions applied to address it, the client’s response, and the next steps in the treatment plan.
PIE (Problem, Intervention, Evaluation): This note type structures documentation around the identified problem, the intervention used, and an evaluation of the intervention's effectiveness.
For Prescribers
Initial Evaluation: This note type is used for documenting the first session or assessment of a client by a prescriber. It includes detailed information on the client's medical and mental health history, symptoms, and possible diagnosis, forming the basis for treatment planning.
Follow-Up: This note type is for follow-up sessions with a prescriber. It includes updates on the client’s progress, medication management, and any changes in treatment or diagnosis since the initial evaluation.
Follow-Up with Add-on Therapy: Similar to a follow-up note, but with additional information on new or supplementary therapies. This is used when an add-on therapy (such as an additional medication or therapeutic approach) is introduced to the client’s treatment plan.