SOAP vs DAP vs BIRP vs GIRP — formats explained, with examples

Why the format matters The format your notes use is dictated by your license board, supervisor, payor and (sometimes) your EHR — not by you. Picking the wrong format means rework at audit. This guide explains the four formats every therapy-first AI scribe supports, with the same vignette written in each.

The vignette *Client, 34F, session 7. Presenting with generalized anxiety. Today: work stressor, mild sleep disruption, no SI. Continued CBT cognitive restructuring; assigned thought record between sessions.*

SOAP — Subjective, Objective, Assessment, Plan The default medical note. Common in psychiatry, integrated-care and any setting that bills with a medical record.

• S: Client reports increased anxiety over a new project deadline at work; describes "spinning thoughts" at bedtime, sleep onset delayed by ~45 minutes. Denies SI/HI.
• O: Mood anxious, affect congruent and reactive. Speech normal rate. Cognition intact. Engaged throughout.
• A: GAD, moderate severity, situationally exacerbated. No acute risk.
• P: Continue weekly CBT. Assigned thought record (3 entries/day). Sleep hygiene psychoed. Next session in 1 week.

Awkward in pure talk-therapy because "Objective" leaves you describing MSE and presentation in a section designed for vitals and labs.

DAP — Data, Assessment, Plan Collapses Subjective + Objective into a single "Data" section. Fits talk-therapy more naturally; widely used in counseling and psychotherapy.

• D: Client reports work-related anxiety with sleep disruption; "spinning thoughts" at bedtime. Mood anxious, affect reactive. Denies SI/HI. Engaged with cognitive restructuring around catastrophic prediction "I will be fired."
• A: GAD, moderate, situationally exacerbated. Cognitive distortions (catastrophizing, fortune-telling) identified. No acute risk.
• P: Continue CBT weekly. Thought record between sessions. Sleep hygiene reviewed.

BIRP — Behavior, Intervention, Response, Plan Common in clinical social work, case management and SUD treatment. Explicitly documents what intervention you applied and how the client responded — which Medicaid and many state payors require to evidence medical necessity.

• B: Client presented anxious re: work deadline; reported sleep onset latency ~45 min; cognitions included "I will be fired."
• I: Provided psychoeducation on catastrophic thinking. Guided cognitive restructuring using evidence-for / evidence-against. Introduced thought-record homework. Reviewed sleep hygiene.
• R: Client engaged, generated alternative thoughts independently by mid-session. Reported reduction in distress (SUDS 7→4). Agreed to thought-record homework.
• P: Continue weekly CBT. Review homework next session. Re-assess if sleep does not improve in 2 weeks.

GIRP — Goal, Intervention, Response, Plan The strictest form of the "golden thread." Each note ties to a specific treatment-plan goal. Required by some Medicaid programs and most CCBHC documentation.

• G: Treatment goal #2: Reduce GAD symptoms (GAD-7 from 14 → ≤7) within 12 weeks via CBT.
• I: Cognitive restructuring around work-deadline cognitions; thought-record assigned; sleep hygiene psychoed.
• R: Client engaged, SUDS 7→4 in session; agreed to homework.
• P: Continue weekly CBT toward Goal #2. Re-administer GAD-7 at session 10.

Tool support today

Picking a format 1. Ask your supervisor or compliance lead what they expect to see at audit. 2. Check your largest payor's documentation guide — Medicaid in many states mandates BIRP or GIRP. 3. Default to DAP for cash-pay psychotherapy where no one is dictating the format. 4. Stay consistent across notes for the same client — the golden thread breaks if you switch formats mid-treatment.

AI scribes are flexible. Your documentation reviewers are not.