Therapy Progress Note Writer, SOAP or DAP

In the US, HIPAA gives one kind of therapy note extra protection. Psychotherapy notes¹ are your notes documenting or analyzing the conversation in a session, kept separate from the rest of the record. They exclude session start and stop times, medication prescribing and monitoring, the types and frequency of treatment, and test results. They also exclude any summary of diagnosis, symptoms, functional status, the treatment plan, prognosis or progress. Those belong in the progress note.

Sharing psychotherapy notes generally takes the client's authorization², even with an insurer, and HIPAA's right of access³ doesn't cover them. Progress notes get only HIPAA's ordinary protections: clients can usually get copies, and insurers can review them.

Medicare's manual for claim reviewers adds that putting both kinds of material in one document doesn't turn the progress note content into protected psychotherapy notes⁴. Reviewers are told never to ask for psychotherapy notes, so the progress note has to show, on its own, why each session was needed.

One Medicare contractor's policy shows the detail payers look for. First Coast, which covers Florida, Puerto Rico and the US Virgin Islands, requires the record for each psychotherapy session to show why it was medically necessary. Its policy calls for a detailed summary of the session, including descriptive documentation of therapeutic interventions⁵, the client's participation and reaction, and whether symptoms or behavior changed.

The headings are only a filing system. Medicare's review manual says progress notes may be in any form or format⁴, though it discourages check-box templates because they often miss the clinical detail reviewers need. Use the format your practice or agency requires, the same way every time.

• SOAP: Subjective (the client's report), Objective (your observations and scores), Assessment, Plan.
• DAP: Data, Assessment, Plan, with report and observations together under Data.
• BIRP: Behavior, Intervention, Response, Plan, built around what you did and how the client responded.

A note has to show that therapy happened. First Coast's policy is blunt: statements such as "supportive psychotherapy given" are not adequate⁵. Name the technique, what you did with it and how the client responded, in numbers when you can.

Describe behavior instead of labeling it: "arrived 15 minutes late and checked her phone often," not "resistant." Quote the client where it matters, and put new scores beside earlier ones. The same policy notes that progress may be small or not measurable at each visit, but a trend should be measurable⁵.

Report on every treatment plan goal by number, even when nothing changed. If the goals can't be measured, fix the plan first: a treatment plan with measurable goals gives each note something to report against. First Coast also expects plans to be updated, generally at least every 3 months.

If you're referring the client, say for a medication evaluation, record to whom and why; a referral letter carries your question to the prescriber.

When a client mentions suicidal thoughts or self-harm, the note should show what you asked, concluded and did. SAMHSA, the federal behavioral health agency, publishes SAFE-T, a two-page suicide assessment guide for clinicians. It lists what to document: the risk level and your rationale, the plan to reduce current risk, lethal means counseling and the follow-up plan⁶. It also says clients should get a copy of their safety plan.

SAFE-T calls for an assessment at first contact and again after any new suicidal behavior, increased ideation or other pertinent clinical change, and before changes in treatment. Write "denies suicidal ideation" only if you asked, and never let a template add "no safety concerns" for you.

Psychotherapy codes are billed by time. First Coast lists 16 to 37 minutes for 90832, 38 to 52 for 90834, and 53 or more for 90837⁷, with no psychotherapy code for sessions under 16 minutes. It also names missing face-to-face time as a concern in Medicare's error-rate reviews. Record start and stop times, or total minutes.

Write and sign the note the same day if you can. Medicare's review manual expects services to be documented in the medical record at the time they are rendered⁴. For anything added or corrected later, use a dated addendum that shows who made it and clearly marks what changed.

If an insurer still denies a session, the note is your evidence. An insurance denial appeal letter uses it to answer the payer's stated reason.

For a first draft, paste your shorthand into the tool at the top of this page. It writes the note in your format and lists what's missing, such as session time or a risk plan.