DAP, BIRP and SOAP Notes for Therapists: Formats and Examples

DAP, BIRP and SOAP are three layouts for the same thing: the therapy progress note that goes in the record and supports the claim. DAP is Data, Assessment, Plan; BIRP is Behavior, Intervention, Response, Plan; SOAP is Subjective, Objective, Assessment, Plan. Ona ships templates for all three and drafts them from the session.

Quick answer:

• Pick one format per practice and use it every time. Consistency matters more to a reviewer than which of the three you chose.
• Every format has to carry the same billing facts: time, interventions, the patient's response, and progress against treatment plan goals.
• A progress note is not a psychotherapy note. HIPAA treats them differently, and mixing them is the most common documentation mistake in therapy practices.

What a Progress Note Has to Do

A progress note has three readers: the next clinician, the payer, and anyone who reviews the record later. It has to tell each of them what happened, why it was necessary, and what comes next.

First Coast Service Options, a Medicare Administrative Contractor, sets out what a psychotherapy session note should contain in LCD L33252: the symptoms that bring the patient below their usual functioning, a summary of the session naming the specific interventions, the patient's participation and response, progress toward treatment plan goals, and the reason for any departure from the plan. Its billing article A57520 adds that time-based psychotherapy codes need start and stop times or total time documented. Every format below is a way of arranging those same elements.

The Three Formats Side by Side

	DAP	BIRP	SOAP
Sections	Data, Assessment, Plan	Behavior, Intervention, Response, Plan	Subjective, Objective, Assessment, Plan
Where interventions go	Inside Data or Assessment	Their own section	Usually in Plan or Objective
Where the patient's response goes	Assessment	Its own section	Assessment
Typical users	Counselors and therapists who want a short note	Practices where payers or programs want interventions spelled out	Integrated and medical settings, prescribers
Strength	Fast to write, easy to read	Makes the intervention-response link explicit	Shared language with medical colleagues
Watch for	Interventions buried in Data	Behavior section turning into a transcript	Objective section left thin in talk therapy

None of the three is required by HIPAA or by Medicare. The LCD cares about content, not headings. Choose the one that fits how your clinicians think, and build the billing facts into it.

DAP Notes: Format and Example

Data is what the patient reported and what the clinician observed. Assessment is the clinician's interpretation: how the session relates to the diagnosis and the goals. Plan is what happens next.

Fictional example. Not a real patient; no PHI.

Session: Individual psychotherapy, 10:02 to 10:55 (53 minutes), video, patient at home. Data: Client reported three nights of interrupted sleep before a work deadline and said she used the breathing exercise from the last session twice. Appeared tired, engaged, speech normal in rate. Completed the weekly worksheet. Assessment: Client is applying the skill outside session but only under acute stress. Session used cognitive restructuring on the belief "if I miss this deadline I will be fired." Client generated two alternative explanations with prompting. Progress toward goal 1 (use one coping skill daily) is partial. Plan: Continue weekly sessions. Practice the skill once daily, not only when stressed, and log it. Next session: review log, continue cognitive work on work-related beliefs.

BIRP Notes: Format and Example

Behavior is the presentation and what the patient brought. Intervention is what the clinician did, named specifically. Response is how the patient responded. Plan is next steps. BIRP is the format that makes it hardest to skip the intervention, which is why many group practices standardize on it.

Fictional example. Not a real patient; no PHI.

Session: Individual psychotherapy, 14:00 to 14:41 (41 minutes), in person. Behavior: Client arrived on time, described an argument with a roommate and said he "shut down" again. Calm, cooperative, made limited eye contact early in the session. Intervention: Reviewed the argument using a chain analysis. Role-played an assertive request. Introduced a two-step script for pausing a conversation. Response: Client identified the point where he stopped talking and practiced the script twice, the second time without prompting. Said the script "feels awkward but doable." Plan: Use the script once before next session and note the outcome. Continue weekly. Revisit treatment plan goals at the next scheduled review.

SOAP Notes for Therapy: Format and Example

Subjective is the patient's report in their own terms. Objective is what the clinician observed or measured. Assessment is the clinical interpretation. Plan is next steps. SOAP is the format medical colleagues already read, which is why integrated practices and prescribers often prefer it. The AI SOAP note generator article covers how Ona drafts SOAP notes; the example below is the therapy version.

Fictional example. Not a real patient; no PHI.

Session: Individual psychotherapy, 09:30 to 10:10 (40 minutes), video, patient at home. Subjective: Client said the week was "better than last" and that he attended the social event he had been avoiding, leaving after an hour. Objective: Alert, oriented, affect brighter than prior session. Completed the exposure log for four of seven days. Screener completed at intake, reviewed in the chart. Assessment: Client is following the graded exposure plan and reports less avoidance. Session focused on processing the event and planning the next step on the hierarchy. Progress toward goal 2 is on track. Plan: Next exposure step agreed. Continue weekly sessions. Update the treatment plan at the next scheduled review.

Notice what all three examples share: a time statement, named interventions, the patient's response, and a link to a numbered goal. That is the part a reviewer checks, whatever the headings say.

Psychotherapy Notes vs Progress Notes: The HIPAA Line

This distinction causes more confusion than any note format. The HIPAA Privacy Rule, at 45 CFR 164.501, defines psychotherapy notes as notes recorded by a mental health professional documenting or analyzing the contents of conversation during a counseling session, kept separate from the rest of the medical record.

The same definition says what psychotherapy notes are not. They exclude medication prescription and monitoring, session start and stop times, the modalities and frequencies of treatment, results of clinical tests, and any summary of diagnosis, functional status, treatment plan, symptoms, prognosis and progress to date. In other words, everything a DAP, BIRP or SOAP note contains belongs in the progress note, not in psychotherapy notes.

HHS explains why the line matters in its HIPAA FAQ on mental health information. Psychotherapy notes get special protection because they are the therapist's personal notes and are typically not needed for treatment, payment or operations by anyone else. With few exceptions, a covered entity needs the patient's authorization to disclose them, per 45 CFR 164.508(a)(2), and they are excluded from the patient's general right of access under 164.524(a)(1). HHS also notes that information kept in the medical record is, by definition, not a psychotherapy note.

	Progress note	Psychotherapy notes
Purpose	The record of care; supports treatment, billing and coordination	The clinician's private analysis of session content
Contains	Time, modality, interventions, response, symptoms, diagnosis, plan, progress	Impressions, hypotheses, details of conversation
Where it lives	The medical record	Separate from the medical record
Sent to payers	Yes, when requested for review	Not as part of routine payment; authorization generally required to disclose
Required?	Yes	No. Many clinicians keep none

Two practical rules follow. Never put the billing facts only in psychotherapy notes, because a payer will not see them and the claim will look undocumented. And never put private process notes inside the progress note, because then they are part of the medical record and lose the special protection.

What Auditors Look For

Reviewers reading a therapy record ask a short list of questions, and the LCD and payer guidance tell you which ones:

• Is the time there, and does it match the code? Start and stop times or a total, consistent with the CPT code billed. Optum's October 2025 guidance lists session time that matches the code among its top checks, with signature and credentials.
• Are interventions named? LCD L33252 says a generic entry such as "supportive psychotherapy given" is not adequate.
• Is there a response and a link to goals? The patient's participation, their reaction, and progress against the treatment plan.
• Is the treatment plan current? The LCD expects plans to be updated, generally at least every three months.
• Do the notes read like this patient? Identical paragraphs across sessions or across patients are a red flag, whether they came from copy and paste or from a template filled carelessly.
• Was the note signed, and are corrections visible? A note edited after the fact without a trace is harder to defend than one with a dated amendment.

Templates and AI Drafting in Ona

Ona is an AI-native, all-in-one practice management platform for outpatient practices, used by solo therapists and by multi-location behavioral health groups that need every clinician's notes to read the same way. The documentation workflow, from Ona's own pages:

Templates for all three formats. Ona's AI charting library includes Progress Note (DAP), Progress Note (BIRP) and Office Visit (SOAP), alongside a Therapy Progress Note, Mental Status Exam and Treatment Plan Update. Import one and edit it. Per the note templates guide, bracketed placeholders such as [session start time], [interventions used] or [progress toward goal] become the fields the note fills, and the fixed headings print exactly as written.

Drafts from the session, decisions from the clinician. With the ambient scribe recording the session in the room or on video, Ona fills the template from what was said, the intake answers and the chart. A field the record does not support is marked as left empty by Ona rather than filled with a guess, so a missing risk answer or time stays visibly open for the clinician. Every change Ona proposes waits for Keep or Discard. Transcription and drafting run in English today.

Signing locks the note. A signed note becomes part of the legal record. Later edits become amendments with a required reason and a line-by-line diff, which is the visible correction history auditors expect.

Billing rules can require the note. Ona's billing rules include a check that requires at least one documentation note before a visit can be billed, so a claim does not leave without the progress note behind it.

What Ona does not describe. Ona's help pages do not describe a separate compartment for HIPAA psychotherapy notes. Its patient notebook is a free-text area, and signed notes can be shared to the patient portal on request. If your practice keeps psychotherapy notes, decide where they live under your own policy, and keep them out of the progress note template and out of any note you share. For the wider view of documentation software, see behavioral health documentation software that survives an audit.

Frequently asked questions

What is the difference between DAP and BIRP notes?

DAP has three sections: Data, Assessment and Plan. BIRP has four: Behavior, Intervention, Response and Plan. BIRP gives the clinician's intervention and the patient's response their own sections, which makes the link between them explicit. DAP is shorter and folds both into Data and Assessment. Both can carry everything a payer expects.

Are SOAP notes used in therapy?

Yes. SOAP, for Subjective, Objective, Assessment and Plan, is common in integrated and medical settings and with prescribers, because medical colleagues already read it. In talk therapy the Objective section needs care: observations of presentation, behavior and completed work belong there, so it does not end up empty.

Are progress notes the same as psychotherapy notes?

No. Under the HIPAA Privacy Rule, psychotherapy notes are a clinician's notes analyzing session conversation, kept separate from the medical record. They exclude session times, modalities, test results and any summary of diagnosis, symptoms, treatment plan or progress. Those belong in the progress note, which is part of the medical record and supports billing.

What must a therapy progress note include for insurance?

Medicare contractor guidance asks for the symptoms affecting functioning, the specific interventions used, the patient's participation and response, progress toward treatment plan goals, and the reason for any change in plan. Timed psychotherapy codes also need start and stop times or total time. A generic line such as "supportive psychotherapy given" is not enough.

Which note format is best for a group practice?

The one every clinician will use consistently. Reviewers care that the content is there, so a group that standardizes on one format, with time and goal fields built into the template, is better protected than one where each clinician uses a different layout. Many groups choose BIRP because it makes interventions hard to skip.

Can Ona write DAP and BIRP notes?

Yes. Ona's template library includes Progress Note (DAP), Progress Note (BIRP) and Office Visit (SOAP). Pick a template on the visit and Ona drafts the note from the session recording, the intake answers and the chart. The clinician keeps or discards each change and signs, and later corrections become amendments with a reason.

Next step

The fastest test is your own template. Import Ona's DAP or BIRP template, add your time and goal fields, record a practice session with a colleague, and read the draft before you sign it. See AI charting and the pricing page, or book a 15-minute demo. The 14-day free trial needs no credit card.