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This BIRP notes template includes sections for recording the patient's behavior, interventions provided, response to interventions, and the future treatment plan. With Heidi, the AI medical scribe for all clinicians, you can take advantage of AI to automatically generate BIRP notes that:
A BIRP notes template is a structured format used by healthcare professionals to document a patient’s current presentation and response to treatment. The acronym stands for behavior, intervention, response, and plan. Here’s a very brief indication of the type of information recorded for each section:
Each session gets its own BIRP note, which helps therapists track a patient’s progress over time.
In this article, we’ll break down the different types of BIRP notes templates, share tips and examples on how to create your own BIRP notes, and briefly explain the difference between BIRP notes and SOAP notes. Lastly, we’ll provide ready-made and customizable BIRP notes templates so you can adjust them based on your practice’s needs.
BIRP note format templates may vary based on the healthcare professional’s specialty and practice setting. BIRP notes always include the same four main sections: Behavior, Intervention, Response, and Plan. However, a customized speciality-appropriate template may also include additional prompts to streamline the documentation process.
Here’s a list of common BIRP note template types used in healthcare, with a focus on specialty-specific customization:
A mental health BIRP notes template focuses on recording psychiatric, emotional, and cognitive observations. It also covers any medications prescribed, therapy delivered, and the patient’s overall response to treatment.
Substance abuse and addictions professions require a BIRP note template that covers relapse triggers, coping mechanisms, and progress in addiction recovery.
A physical therapist’s BIRP note template might include prompts to address mobility issues, pain levels, employed therapeutic exercises, and rehabilitation progress.
In pediatric settings, BIRP notes typically document a child’s behavior and developmental milestones. Treatment and therapeutic interventions are often highly specialized in this cohort, leading to some providers adding custom prompts to their templates.
Both BIRP and SOAP notes are structured documentation methods used in healthcare, but their main differences lie in their specific focus.
SOAP Notes (Subjective, Objective, Assessment, Plan) is the preferred documentation method for medical settings, since it combines patient-reported symptoms and objective clinical observations. A SOAP template allows doctors to document measurable health data (e.g., vital signs) to create a clear medical assessment that leads to a treatment plan.
In contrast, because of their focus on behavioral observations and therapeutic responses, BIRP notes are typically used in therapy and mental health fields.
For example, a SOAP note for a physical therapy session might document the objective results of muscle strength tests, while a BIRP note for a counselling session would focus on the patient’s emotional responses and coping mechanisms.
As mentioned earlier, a BIRP note’s meaning and exact fields may vary on a case-by-case basis. For the sake of this example, we’ll use a BIRP note designed for mental health practice.
Start by detailing the patient’s mood and general behavior throughout the therapy session.
Example: The patient presented with a depressed mood and flat affect. They exhibited signs of anxiety, including fidgeting and avoiding eye contact.
Outline the treatments and strategies used during the session, specifying how they’re meant to address the patient’s needs.
Example: Cognitive-behavioral therapy techniques were employed to address the patient's negative thought patterns. Additionally, relaxation exercises were introduced to help manage anxiety symptoms.
Record how the patient reacted to the intervention, including improvements, challenges, or concerns.
Example: The patient showed slight improvement in mood and was able to engage more actively in the session. They reported feeling somewhat relieved after the relaxation exercises.
Note the next steps in treatment including follow-ups, referrals, or adjustments.
Example: Continue with weekly therapy sessions focusing on cognitive-behavioral techniques. A referral to a psychiatrist for medication evaluation was made. Follow-up appointment scheduled for next week.
You can download a copy of this document, or auto-fill it seamlessly with Heidi, your AI care partner.
After each therapy session, clinicians often have to set time aside to manually complete their BIRP notes for each patient. The routine paperwork adds up, and before long, several hours are lost to administrative work. Luckily, through AI advancements in the healthcare field, we can provide a more efficient way to streamline your BIRP note documentation.
Meet Heidi, our cutting-edge AI medical scribe designed to help you complete your BIRP notes while conducting therapy sessions. With your patient’s permission, simply hit record and let Heidi get to work alongside you!
Here’s how Heidi helps you accomplish your BIRP notes:
Heidi is compliant with international data privacy and security standards, including HIPAA, ISO 27001, and SOC 2 certifications. We adhere to jurisdiction-specific regulations, ensuring strict data localization for customers in Australia, Canada, the United States, and the United Kingdom.
Read more about our compliance here and check out this case study of Heidi in use at a large multi-specialty behavioral health practice in Indiana.
BIRP notes should be written as objectively as possible. Common mistakes to avoid include using vague language without supporting details. For example, instead of simply saying, “The patient seemed anxious”, it would be better to say, “The patient exhibited fidgeting, rapid speech, and avoided eye contact.”