Introduction
As a mental health therapist, you’ve likely heard of the term BIRP notes before. If not, that’s okay! We’re here to help guide you through BIRP notes for mental health, and how they can be used to elevate and enhance the quality of your practice in no time. The term BIRP stands for Behavior, Intervention, Response, and Plan, and is widely used by over 80% of practitioners to communicate client information and record the patient experience. They are an excellent way to note the progress of a patient’s mental health condition and are great for sharing information succinctly, streamlining the documentation process.
What is a BIRP Note?
As briefly touched on, a BIRP note is a progress note form, commonly used by mental health therapists, that explains and records clinical information pertaining to an individual’s mental health. It describes the patient’s behavior, the intervention that is needed, or that has previously been provided for the patient, as well as the response to such interventions, and future steps.
They are necessary progress notes that have several purposes:
- Support legal obligations
- Help guide mental health practitioners on the future course of action for the patient at hand
- For reimbursement and insurance purposes.
For medical billing and coding processes, you may need to provide evidence of the exact resources and treatment used, and BIRP notes act as excellent reference notes for you to mention. BIRP notes are essential clinical records and documents that almost every healthcare practice incorporates in their services, so becoming acquainted with their purpose is absolutely critical.
BIRP notes vs SOAP notes - How are they different?
BIRP notes and SOAP notes are both formats for progress note documentation, so it’s definitely understandable that they sometimes get mixed up. The most important distinction between them is how they lay out the relevant information for a progress note.
- BIRP notes are separated into Behavior, Intervention, Response and Plan.
- SOAP note sections are Subjective, Objective, Assessment and Plan.
At the end of the day, the same information should be covered regardless of what kind of progress note template you use, and it will mostly come down to personal preference. However, although we think that both BIRP and SOAP notes have their benefits, we would encourage consistency. Using the same format across all of your client documentation will make accessibility much easier, in addition to helping other providers find the relevant information within your notes as quickly as possible.
Why are BIRP notes important for mental therapists?
For mental health therapists specifically, there are many reasons why BIRP notes are important. These include the following reasons:
Fast notes – Using BIRP formats allow you to record all essential details without compromising on time. In fact, using these notes will allow you to record information quickly, with the format only concerned with core components that directly relate to the treatment of the patient.
Accurate information – Because BIRP notes are progress notes, this means that each additional session with a patient provides an updated record of their mental health condition. As a result, all healthcare providers are seeing the most accurate, up-to-date information pertaining to patient health.
Avoids miscommunication – BIRP notes are great at laying out all the essential details to clarify any concerns or queries that healthcare practitioners may have. Due to their universal format, this also means that healthcare professionals can easily understand and decipher the content, which ensures that only the right medications are prescribed and that the appropriate treatment is given.
Legal support – Additionally, BIRP notes are a great way to safeguard you and your practice in the case that your notes need to be used in a court proceeding. Alternatively, if you become involved in a malpractice suit, having BIRP notes can legally support you and ensure that you’re compliant.
Demystifying the different sections of BIRP notes
There are four core elements of each BIRP note that must be included in order to fulfill all its components, these being behavior, interventions, response, and plan. To help guide you, we’ve outlined all the essentials you need to know when it comes to creating these notes.
Behavior – In this section, all objective and subjective observations concerning the patient’s mental health condition need to be noted. For the subjective information, this means noting the patient’s experience directly from the patient themselves, with direct quotes used as supporting evidence. Objective details need to also be written concerning the patient’s vitals, tests, as well as any other medical assessments. These should be irrefutable facts that other medical professionals would also be able to notice in the patient.
Interventions – Next, you should include information concerning the objectives and goals of the patient’s therapy. Ideally, you should summarize the conversation, any current techniques used, as well as any present actions taken.
Response – Here, you need to record the patient’s response to their intervention, and how they feel it is working. All reactions should be noted, as they help guide the course of action and what can be done next regarding the patient’s health.
Plan – As the final stage, this step outlines the next steps for the patient. This means you must note when the next session will take place, and what it will focus on. Bear in mind that you also need to write down any homework or exercises given to the patient that needs to be checked next time, so you can remember. It can be difficult to keep track of what treatment is given, and writing it down can be immensely beneficial for you to refer to in the future.
What should be the ideal length of BIRP notes?
It’s quite difficult to provide a guide for how long the ideal length of a BIRP note should be. Although the ideal progress note is concise, each client session will vary significantly. That being said, you should try to remember that the purpose of BIRP notes (and any other progress note format) is to produce brief but accurate documentation. So basically, the shorter the better - as long as you are covering everything that’s relevant!
However, there will be some occasions that arise when writing longer BIRP notes is necessary. These may include the following:
- Crisis issues have been observed
- Treatment plan has had a significant change
- Risk factors are addressed
- Medication has been changed
Checklist to write great BIRP Notes
Now that you know the essentials of BIRP notes, it’s helpful to understand ways to enhance them, and provide deeper insight when it comes to evaluating your patient’s mental health. Firstly, you must make sure to include any relevant demographic information, especially:
- Age
- Gender
- Employment
- Living situation
Any diagnoses and medications must also be noted, as this can influence the direction of the conversation, as well as any resulting treatments. When first presenting the problem, it’s also helpful to note the experience in the patient’s words to avoid missing important information or misrepresenting their concerns. This includes any safety issues, such as self-harm, that can pose a risk to some forms of treatment and assessment.
Including this type of information will help when you begin to address client goals and objectives, and the steps required in order to achieve such goals. Sometimes taking special note of their current mental status, or any unusual behaviors, can aid in a greater understanding of their progress, and so this should also be included in addition to any symptoms presented. Covering all this information should allow you to produce valuable notes, with plenty of content to work with in order to address the patient’s main concerns and prioritize their mental state.
Interventions to consider for BIRP notes
Given how versatile BIRP notes are, they can be used effectively in a wide range of different healthcare fields. These include (but are not limited to):
- Psychotherapists: To help track the progress of patients being treated with psychological methods across a range of emotional difficulties or mental disorders.
- Counselors: Can be used for patients of all ages, including children, teenagers and adults.
- Psychologists: To consolidate general information regarding patients who are being treated for their mental health.
- Cognitive behavioral therapists: Often referring to the treatment of depression, anxiety and trauma.
- Psychiatrists: To assist with medication related and other treatment interventions.
- Nurses: Especially useful for coordination of care for nurses in in-patient care.
BIRP Note examples for Mental Health Therapists
Sometimes it can be easier to understand BIRP notes when given an example, and as a result, we’ve created a common BIRP template note for you to follow in your practice. Keep in mind that every note can look a little different, however, if you follow the four core components, you should be on the right track toward successfully assessing patients.
Counseling BIRP Note Example:
Behavior
Met with John today in the office, and noticed that he looked fatigued, with visible signs of exhaustion. John reported being unable to sleep well in the past week and had recurrent thoughts about work that were difficult for him to dismiss. Such thoughts had led him to concentration problems, as he confirmed.
Interventions
All of John’s negative thoughts were identified and challenged. The connection between his insomnia and his work troubles was made and normalized through discussion. Distraction techniques were provided, in addition to sleep aids prescribed, in order for John to be able to function normally throughout his day.
Response
John rejected the link between insomnia and work stress, however, this was overcome. He was initially disengaged throughout the conversation with reduced eye contact, however, he was able to describe his feelings and relay them back to me.
Plan
John will be seeing me next Thursday the 8th. This will assess the sleep aid and distraction techniques, and whether his feelings about work have had any significant changes.
Psychotherapy BIRP Note Example:
Behavior: Sally was well groomed and neatly dressed. She was responsive and engaged during the session and fully oriented. Sally said her anxiety symptoms have been stable since her previous session. No risk of suicide or other forms of violence.
Intervention: Sally worked on mindfulness exercises and revisited the 5-4-3-2-1 method.
Response: Sally said she was applying mindfulness into her everyday life. Sally has begun regular meditation. She said these sessions make her “feel calm”.
Plan: Sally’s next session is scheduled for next Wednesday, 12/06/2023 at 11:00am. Sally is going to focus on practicing meditation every morning over the next week.
Psychiatry BIRP Note Example:
Behavior: Roger presented with a flat affect. He complained of having a low mood that has been preventing him from participating in everyday activities. Roger’s self-esteem appeared low. He did not report sleep disturbance, change in appetite or concentration.
Intervention: Roger learned how to replace negative self-talk with positive self-talk. Practiced breathing techniques.
Response: Roger was able to recognize his negative thoughts. He exhibited some anxiety but breathing techniques allowed him to relax.
Plan: Roger referred to a psychotherapist to begin weekly sessions.
Mental Health Worker BIRP Note Example:
Behavior: Hannah has reported feeling extreme anger. Hannah’s participation in the session was normal and she expressed interest in learning healthy coping mechanisms. No signs of anxiety were present. Judgment appears intact.
Intervention: Hannah was taught methods to improve her frustration tolerance. She acknowledged knowing how to identify when her response to situations is escalating.
Response: Hannah stated her gratitude in learning how to control her anger responses. She learned how to identify patterns in her excessive emotional responses.
Plan: Hannah will focus on removing herself from situations that elicit strong emotional responses. Hannah’s next session is next Tuesday 04/07/2022 at 1:00pm.
Group Therapy BIRP Note Example:
Group Topic: The group therapy session was focused on sobriety management and abstaining from drug use. The group participants were all asked to share how their sobriety is progressing and any recent changes in their life. The group facilitator led a discussion on coping mechanisms to prevent relapse.
Behavior: Sam participated during the session. He was well groomed and neatly dressed, and contributed to the conversation. Sam shared that he has now been sober for 10 months. Sam admitted to still having cravings but these have reduced to 1-2 times a day.
Intervention: Sam was encouraged to continue exercising and playing weekly social basketball games. Sam was taught how to set boundaries with his friends and family that engage in recreational drug use.
Response: Sam appeared excited about the progress he has made. He knows how to identify when his cravings are worsening and coping mechanisms to alleviate these.
Plan: Sam is going to set boundaries with friends and family members so he isn’t in proximity to recreational drugs. Sam will continue coming to weekly group therapy sessions.
BIRP note template
To help you perfect your BIRP notes, we’ve created a useful template. Feel free to download, edit or amend the template to suit your professional preferences.
Carepatron’s BIRP note template
Using technology for BIRP notes
With the constantly changing world of technology, there are a range of clinical documentation platforms that can help with the production of BIRP notes. Essentially, this type of software is integrated with specific tools that are designed to streamline the process of writing documentation, saving you both time and money.
Carepatron, an all-in-one healthcare software, is the perfect example for this type of platform. The system is integrated with note templates and voice-to-text transcription, both of which will guarantee your BIRP notes are accurate and consistent. Additionally, Carepatron takes compliance very seriously. With sophisticated encryption, safeguards and physical security, you can store your BIRP notes safely and protect patient privacy at all times. Benefits of using Carepatron’s software include:
- Accessibility: With Carepatron, all of your patient’s care team will be able to quickly and effectively access the relevant BIRP notes, leading to better coordination of care.
- Save time: The voice-to-text transcription software that is integrated into Carepatron’s system is guaranteed to streamline your documentation process. After all, speaking is much faster than writing!
- Improved quality of care: Most importantly, using software like Carepatron will help you to improve quality of care. You can spend more time focusing on the needs of your patients, and elevate your communication and consistency.
Conclusion
BIRP notes are a great way to compile all necessary patient information regarding their mental health, and they work to document all signs of progress. Using BIRP notes can provide excellent insight into the subjective and objective assessments of a patient’s experience and current mental health state, as well as note observations to be synthesized for future treatment plans. While they can seem challenging to get your head around, we hope this guide has clarified many of your concerns and outlined how to successfully produce valuable notes. Software, such as Carepatron, provide hundreds of free templates to help you get started with creating high-quality progress notes, however, regardless of your decision, we hope that you can now hit the ground running when it comes to evaluating your patients with care.
One app for all your clinical notes: Try Carepatron for free today!
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