Comparing Types of Clinical Notes: SOAP, BIRP, DAP, and More

Clinical documentation is the foundation of effective patient care. The records and observations can significantly impact treatment plans and communication with other healthcare professionals.

When choosing the correct format for documenting patient interactions, you’ll come across a range of options – each with its benefits and specific use cases. SOAP, BIRP, and DAP are just a few of the most common clinical notes healthcare providers use. But which one is the best for your practice?

In this blog, we’ll explore the key differences between these clinical note formats, highlight their strengths, and provide practical guidance on choosing the most appropriate one for your needs and workflow.

Overview of Clinical Note Types

Clinical documentation is essential for maintaining accurate records, improving patient outcomes, and facilitating effective communication among healthcare providers. Several formats are available, but SOAP, BIRP, and DAP notes are among the most widely used. Each format focuses on different aspects of the patient’s condition and treatment, making it easier for healthcare professionals to document care efficiently.

1. SOAP Notes: SOAP notes are particularly effective in general medical practice for capturing the patient’s narrative and the clinician's findings.

This widely used format includes four key sections:

• Subjective: The patient's initial concerns and symptoms.
• Objective: Clinical findings and test results.
• Assessment: The clinician’s diagnosis or clinical impression.
• Plan: Next steps in treatment or management.

This format is essential for organising patient information into clear categories, ensuring a comprehensive record of symptoms, assessments, and treatment plans.

2. BIRP Notes: Commonly used in mental health and therapy settings, BIRP notes focus on patient response.

This format is essential for tracking patient behaviour and responses to interventions.

• Behaviour: Observations of the patient’s behaviour during a session.
• Intervention: The therapeutic approaches used.
• Response: The patient’s reaction to the intervention.
• Plan: Next steps or adjustments to treatment.

BIRP notes organise client progress, ensure treatment tracking, improve communication, and support compliance in mental health care through structured documentation of behaviour, interventions, responses, and plans.

3. DAP Notes: A streamlined format with three core sections, DAP notes focus on observing data used primarily by therapists, counsellors, and psychologists.

DAP notes are often used in urgent care settings, where fast, efficient documentation is essential.

• Data: Key facts, such as patient history or findings.
• Assessment: The clinical interpretation of the data.
• Plan: The proposed treatment or action.

Now that we understand the common note types, let’s explore each in detail.

SOAP Notes Explained

SOAP notes, which stand for Subjective, Objective, Assessment, and Plan, are essential for organising patient information into clear categories, ensuring a comprehensive record of symptoms, assessments, and treatment plans. Here's how each section works

• S - Subjective: This section captures the patient's words regarding their symptoms, concerns, or history. It is often the starting point of the note, providing insight into the patient’s experience.
• O—Objective: The objective section focuses on measurable data such as vital signs (blood pressure, heart rate), lab results, and physical exam findings. Here, clinicians document concrete, observable facts that help assess the patient’s condition.
• A - Assessment: The assessment section synthesises subjective and objective data. Based on the collected information, the section bridges the gap between the patient's reports and what is observed during the exam.
• P—Plan: The plan outlines the next steps in the patient’s care. It could include treatment options, specialist referrals, follow-up appointments, or lifestyle recommendations. The plan is critical to ensuring that the patient’s condition is managed actively.

Here is an example of a SOAP note for better understanding.

Client Name: John DoeDate: 18 December 2024Session Number: 3Clinician Name: Dr. Sarah Wilson, Psychologist

• S - Subjective ReportThe client reports feeling "constantly worried" about their health and states, "I feel my blood pressure is always high, and I’m afraid it’s going to cause serious issues."He describes experiencing frequent headaches, dizziness, and difficulty relaxing, rating his worry level at 8/10.
• O - Objective ReportThe client displayed a tense posture and intermittent fidgeting throughout the session.Her speech was deliberate and focused on health concerns.Blood pressure was recorded at 150/95 mmHg, aligning with concerns about hypertension.
• A - Assessment ReportSymptoms indicate significant health anxiety, likely contributing to elevated blood pressure readings.Current stressors include concerns over managing diet, exercise routines, and work-related deadlines.
• P - Plan ReportIntroduce progressive muscle relaxation techniques to address tension and stress.Recommend maintaining a daily blood pressure log to track patterns and identify triggers.Refer to a primary care physician for further evaluation and management of hypertension.Schedule the next session for 22 December 2024 to review relaxation techniques and discuss coping strategies for health-related anxiety.

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BIRP Notes Explained

BIRP notes are structured mental health records focusing on behaviour, interventions, responses, and plans, ensuring clear documentation of patient-clinician interactions and treatment progress. Here’s how the sections break down:

• B - Behavior: This section details the patient's observable behaviour during the session. It may include emotional responses, body language, or actions that give the clinician insight into the patient’s state of mind and progress.
• I - Intervention: The intervention section outlines the therapeutic techniques or strategies used during the session. This could include cognitive-behavioural techniques, coping strategies, or any treatment provided to the patient.
• R - Response: In this section, the clinician documents the patient’s reaction to the intervention. This may include changes in behaviour, emotional state, or engagement with the therapeutic process.
• P—Plan: The plan outlines the next steps in the patient's care, including any follow-up sessions, new interventions, or goals to be addressed in future therapy sessions.

Here is an example of a BIRP note for a better understanding.

Client Name: Jane SmithDate: 18 December 2024Session Number: 5Clinician Name: Dr. Mark Taylor, Therapist

B - Behavior

• The client appeared tearful and avoided eye contact at the beginning of the session.
• They expressed hopelessness and stated, "I feel like I’m failing at everything."

I - Intervention

• Provided psychoeducation about cognitive distortions and how they contribute to feelings of failure.
• Guided the client through a cognitive reframing exercise to challenge negative thought patterns.

R - Response

• The client engaged actively in the reframing exercise and identified one positive outcome from the week: "I guess finishing that project on time was something good."
• They reported feeling slightly more optimistic by the end of the session.

P - Plan

• Assign daily journaling to identify and reframe at least one negative thought daily.
• Plan to review the journal entries and explore further cognitive strategies in the next session.
• Schedule the follow-up session for 23 December 2024.

DAP Notes Explained

DAP notes are a concise clinical format with data, assessment, and plan sections, ideal for efficient, clear, and comprehensive documentation in fast-paced healthcare settings. Here's how each section works:

• D - Data: The data section encompasses both subjective and objective observations. It includes patient-reported information (like symptoms or history) and clinician-observed findings (such as vital signs or physical exam results).
• A—Assessment: In this section, the clinician critically analyses the data collected during the session. The assessment combines the patient’s reported symptoms with clinical observations, leading to a diagnostic impression or clinical evaluation.
• P - Plan: The plan focuses on the next steps in the patient’s treatment. It includes follow-up actions, referrals, recommended interventions, or treatment changes based on the assessment. This section ensures that the patient’s care is actively managed moving forward.

Following some best practices that ensure efficiency and clarity in note-taking is essential for enhancing clinical documentation. Here is an example of a DAP note.

Date: 18 December 2024Time: 10:00 AMClinician Name: Dr. Jane Smith, Licensed Clinical PsychologistSession Number: 4

D - Data

• The patient reports experiencing persistent worry and restlessness, especially in social situations.
• Describes difficulty concentrating and feeling fatigued despite adequate sleep.
• I observed fidgeting and avoidance of eye contact during the session.
• Vital signs: Heart rate 88 bpm, within normal range but elevated compared to previous visits.

A - Assessment

• Symptoms align with Generalized Anxiety Disorder (GAD) as described in prior sessions.
• Current stressors include an upcoming work presentation and family conflicts, which may be exacerbating her anxiety.
• The patient demonstrates awareness of triggers but has struggled to implement previously discussed coping strategies consistently.

P - Plan

• Introduce cognitive reframing techniques to help manage negative self-talk related to work presentations.
• Assign a daily 5-minute journaling exercise to identify anxiety triggers and develop positive affirmations.
• Review progress with coping strategies and reassess stress levels in the next session, scheduled for 23 December 2024.

Now that we have learned all about standard clinical notes, let’s explore some essential clinical documentation tips.

Clinical Documentation Tips

Adequate clinical documentation relies on a few key principles that help ensure your notes are accurate and actionable. Here are some essential tips for high-quality note-taking:

1. Timing: Write your notes as soon as possible after a session to ensure that the details are fresh and accurately recorded. Delayed documentation can lead to missed information or inaccuracies. To record notes promptly and to ensure accuracy, streamline your process with platforms like Practaluma today!

2. Thoroughness: Capture all relevant patient data—both subjective and objective—without omitting important details. A comprehensive note ensures that all aspects of care are documented for future reference.

3. Clarity: Keep your notes clear and concise, avoiding unnecessary jargon. Structured formats (like SOAP, BIRP, or DAP) organise information in a way that is easily understandable by other healthcare providers.

4. Legibility: Your notes should be legible, whether digital or handwritten. Clear handwriting or a user-friendly digital format ensures the next clinician can easily read and understand them.

5. Patient Access: As healthcare becomes increasingly patient-centred, ensure patients can access their clinical notes when appropriate. This will build trust and improve the overall care experience.

These practices help ensure your notes are informative and valuable for everyone involved in patient care.

In summary, the choice of clinical note format should be based on your practice's specific needs and goals. Let’s conclude with a final thought on aligning your documentation practices with clinical objectives.

Consider watching this YouTube video to better understand Dr. Maelisa McCaffrey's (QA Prep) clinical notes on what goes on in a counselling progress note.

Conclusion

In clinical practice, the choice of note-taking format is far from one-size-fits-all. Understanding the strengths of each format—SOAP, BIRP, or DAP—is essential for selecting the right one for your clinical setting.

• SOAP notes provide a detailed, structured format for general medical practices.
• BIRP notes are invaluable in behavioural health settings, focusing on the patient's behaviour and response to interventions.
• DAP notes offer a concise, streamlined approach for environments that require quick documentation.

Adequate clinical documentation is critical for delivering exceptional patient care, but it doesn’t have to be challenging. At Practaluma, we specialise in streamlining your workflow with tailored solutions for SOAP, BIRP, and DAP notes. From customisable templates to hands-on training, our services are designed to save you time, enhance accuracy, and ensure compliance with healthcare regulations.

Whether you're a private practitioner, therapist, or part of a larger healthcare team, Practaluma has the expertise to make your documentation process simple, efficient, and effective.

Ready to transform your clinical documentation?Contact us today to learn how we can help your practice thrive. Let Practaluma handle the documentation so you can focus on what matters most—your patients.