Glossary

Therapy-documentation terms, plainly defined.

SOAP note: Subjective, Objective, Assessment, Plan — the most common medical and behavioral-health note structure.
DAP note: Data, Assessment, Plan — favored in therapy where the 'objective / subjective' split is less meaningful.
BIRP note: Behavior, Intervention, Response, Plan — common in clinical social work and case-management settings.
GIRP note: Goal, Intervention, Response, Plan — orients each note explicitly to a treatment-plan goal.
PIE note: Problem, Intervention, Evaluation — used by some social-work programs.
Progress note: The documentation of a single session that is part of the clinical chart and may be shared with payors.
Psychotherapy note: A clinician's personal process notes, kept separate from the progress note and afforded special protection under HIPAA.
Treatment plan: The longitudinal document listing goals, objectives and interventions that anchors the 'golden thread' across the chart.
Golden thread: The clinical-documentation principle that diagnosis, treatment plan, progress notes and discharge summary all reference the same goals in consistent language.
Medical necessity: The payor-required justification that the service rendered was clinically indicated; documentation must support it.
42 CFR Part 2: The US federal regulation governing confidentiality of substance-use-disorder records held by federally-assisted programs; stricter than HIPAA in several respects.
BAA: Business Associate Agreement — the HIPAA-required contract between a covered entity and any third party that handles PHI on its behalf.
ePHI: Electronic Protected Health Information — any PHI created, stored or transmitted electronically.
Ambient scribe: An AI documentation tool that listens to the session in real time and generates the note automatically, vs a tool requiring dictation or summary input.
Telehealth modifier: A CPT modifier (e.g. 95) appended to a procedure code to indicate the service was delivered via telehealth.
MSE: Mental Status Exam — the structured clinical observation typically documented in psychiatric notes.
SIRP note: Situation, Intervention, Response, Plan — a variant favored by some case-management and crisis-response programs.
CPT code: Current Procedural Terminology — the AMA-maintained codes therapists use to bill sessions (e.g. 90834, 90837, 90847).
ICD-10: The diagnostic coding system payors require on claims; the F-codes (F32, F41, etc.) cover most mental-health diagnoses.
PHI: Protected Health Information — any individually identifiable health information held or transmitted by a covered entity, in any form.
Covered entity: Under HIPAA, a health plan, clearinghouse, or healthcare provider that transmits PHI electronically — therapists in private practice usually qualify.
Business associate: A vendor (including an AI scribe) that handles PHI on behalf of a covered entity and must sign a BAA before processing any session data.
Subprocessor: A downstream vendor a business associate uses to process PHI — e.g. the cloud LLM provider behind an AI scribe. Should be disclosed in the BAA.
Zero data retention (ZDR): A vendor configuration where prompts and outputs are not stored or used for training; relevant when an AI scribe routes audio or transcripts to a third-party LLM.
De-identification: Removing the 18 HIPAA identifiers (or applying expert determination) so data is no longer PHI and falls outside HIPAA's use restrictions.
Minimum necessary: HIPAA principle requiring use or disclosure of the least PHI needed for the task — relevant to what an AI scribe ingests and what it writes back to the EHR.
Informed consent (recording): Documented agreement from the client that the session may be recorded or processed by an AI scribe, including what is stored and for how long.
Two-party consent: State wiretap laws (CA, FL, IL, MA, MD, MT, NH, PA, WA and others) requiring every participant to consent before a session is recorded.
Audit log: An immutable record of who accessed or modified PHI and when — required by HIPAA Security Rule and a baseline expectation for any clinical AI tool.
SOC 2 Type II: An independent audit attesting that a vendor's security controls operated effectively over a period (usually 6–12 months). Common evidence requested in BAAs.
HITRUST CSF: A certifiable security framework that maps HIPAA, NIST and SOC 2 controls; some health systems require it of clinical vendors.
EHR / EMR: Electronic Health Record / Electronic Medical Record — the system of record for clinical documentation (e.g. SimplePractice, TherapyNotes, Jane, Osmind).
Write-back: An AI scribe's ability to push the generated note directly into a specific EHR field, vs requiring copy-paste.
Superbill: An itemized receipt with CPT and ICD-10 codes that an out-of-network client submits to their insurer for reimbursement.
Hallucination: When an AI model fabricates content not present in the source (e.g. inventing an intervention or symptom). The core clinical risk in AI-generated notes.
Confabulation: A more clinically-flavored term for AI hallucination — plausible-sounding fabrication, often used in safety literature for LLMs in healthcare.
Diarization: The speech-processing step that labels who-spoke-when. Quality directly affects whether a scribe attributes statements to the right speaker.
ASR: Automatic Speech Recognition — the transcription layer underneath an ambient scribe (Whisper, Deepgram, AssemblyAI, etc.).
WER: Word Error Rate — the standard accuracy metric for ASR; for therapy audio anything above ~10% noticeably degrades note quality.
LLM: Large Language Model — the generative layer that turns the transcript into a structured note (GPT-4o, Claude, Gemini, etc.).
Prompt injection: A class of attack where text in the input (e.g. something a client says) manipulates the model's behavior. A live concern for ambient scribes.
Risk assessment (SI/HI): Documentation of suicidal or homicidal ideation, plan, intent, means and protective factors — a section AI scribes must handle carefully and never invent.
Countertransference: The clinician's emotional reactions to the client. Typically belongs in psychotherapy (process) notes, not the progress note an AI scribe drafts.
Collateral contact: Contact with someone other than the client (parent, partner, prescriber) that is documented in the chart; consent and confidentiality rules differ.
ROI: Release of Information — the signed authorization required before PHI can be shared outside the treatment relationship.
Group note: A progress note for group therapy where each participant's individual response and progress must be documented separately.
Couples / family note: A session note involving more than one client; raises questions about whose chart it lives in and how each participant's PHI is segregated.
No-show / late-cancel note: Brief documentation of a missed session, often required by payors and increasingly auto-drafted by scribes from calendar events.
Concurrent documentation: Writing the note during or immediately after the session — the workflow AI scribes are designed to replace or accelerate.
Measurement-based care (MBC): Using validated instruments (PHQ-9, GAD-7, PCL-5) at intervals to track outcomes; some scribes pull scores into the note automatically.
PHQ-9 / GAD-7: Brief validated self-report measures for depression and anxiety; the most commonly referenced outcome instruments in outpatient therapy notes.
CCM / BHI codes: Chronic Care Management and Behavioral Health Integration CPT codes used in integrated primary-care settings; documentation requirements are time-based.