BIRP Notes Template with Examples [Customizable]

BIRP Notes Template

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:

• Intelligently structure clinical documentation by listing observations, interventions, and responses.
  
• Track treatment progress by securely recording patient progress and improvements to assess therapy effectiveness.
  
• Guide future care by outlining plans for next steps, including potential adjustments, follow-ups, and referrals.
  

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What is a BIRP Notes Template?

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:

• Behavior of the patient
• Intervention techniques employed by the healthcare professional
• Responses of the patient to intervention techniques
• Plans for the next session

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 Examples and Types

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:

1. Mental Health BIRP Notes

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. 

2. Substance Abuse Counseling BIRP Notes

Substance abuse and addictions professions require a BIRP note template that covers relapse triggers, coping mechanisms, and progress in addiction recovery. 

3. Physical Therapy BIRP Notes

A physical therapist’s BIRP note template might include prompts to address mobility issues, pain levels, employed therapeutic exercises, and rehabilitation progress.

4. Pediatric BIRP Notes

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. 

BIRP Notes vs. SOAP Notes: How They Differ

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. 

How to Write a BIRP Note with Examples

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. 

1. Document Observed Behavior 

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.

2. Record Interventions and Techniques

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.

3. Note Responses

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.

4. Outline Plans

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.

BIRP Notes Template Example

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.

Easily Complete BIRP Notes with Heidi

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:

• ‍Transcribe - Open Heidi on your computer or mobile device and press Start. Conduct your session as normal while Heidi captures everything in the background.
• ‍Customize - After the session, pick your preferred BIRP note template and watch as Heidi perfectly transcribes the details of your conversation into the appropriate fields and format!‍
• Transform - After generating your BIRP note template, you can ask Heidi to give additional documentation, like referral forms, medication logs, a patient summary, and more.

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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.

Free BIRP Notes Templates [Customizable]

BIRP Note Format Template

Child therapists can use this template to capture essential elements from therapy sessions, such as the child’s behavior, therapeutic interventions, their response to treatment, and plans for continued management.

View Template‍

Counseling BIRP Notes Template

This template is a structured documentation tool that can be used by mental health counselors to record therapy sessions.

View Template‍

Therapy BIRP Note Template

This template is specifically designed so clinicians can record key observations from couples therapy sessions.

View Template

FAQs About BIRP Note Templates

What are common mistakes to be avoided when writing BIRP notes?

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.”

Can BIRP notes be used in legal or insurance documentation?

Yes, BIRP notes are part of the patient’s medical record, so they can serve as official records in legal or insurance claims.  

How can therapists ensure their BIRP notes remain HIPAA-compliant?

Therapists can maintain HIPAA compliance by using HIPAA-certified documentation tools like Heidi, obtaining patient consent prior to recording therapy sessions, and avoiding the inclusion of personal details that are unnecessary to the patient’s treatment. 

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