| name | documentation |
| description | Use when writing clinical notes, documenting sessions, creating treatment plans for insurance/authorization, ensuring HIPAA compliance, or need structured documentation templates. Provides SOAP notes, progress notes (DAP format), and treatment plan templates. HIPAA-compliant guidance included. |
Clinical Documentation
Description
This skill provides templates and guidance for standard clinical documentation formats used in mental health settings. Includes SOAP notes, progress notes, and treatment plan documentation.
Clinical Context: Clear, concise documentation supports continuity of care, meets regulatory requirements, and protects both patient and clinician. These templates provide structure while allowing for individualized clinical narrative.
Available Templates
| Template | Purpose | Setting | Key Sections |
|---|
| SOAP Notes | Session documentation | All settings | Subjective, Objective, Assessment, Plan |
| Progress Notes | Session summaries | Outpatient/residential | Varies by format (DAP, BIRP, GIRP) |
| Treatment Plan Format | Treatment planning documentation | All settings | Goals, objectives, interventions, timeline |
Response Style
- Start with the relevant quick-reference template.
- Ask if the user wants the detailed examples and expanded guidance.
Quick Reference
| Need | Use |
|---|
| Session note | SOAP or DAP/BIRP/GIRP |
| Treatment plan | Treatment Plan Template |
| Safety issue | Safety Documentation Protocols |
Interactive Mode (Lightweight)
Use this mode when the clinician asks to build a note step-by-step.
- Confirm the note type (SOAP, DAP/BIRP/GIRP, or treatment plan) and setting.
- Ask for required inputs one section at a time and wait for responses.
- If information is missing or unclear, ask targeted follow-ups.
- Draft the note and ask for confirmation or edits before finalizing.
- If safety issues are described, prioritize safety documentation protocols.
Usage
This skill can be invoked when you need to:
- Document therapy sessions
- Write clinical progress notes
- Format treatment plans
- Meet documentation requirements
- Ensure compliance with standards
Example requests:
- "Help me write a SOAP note"
- "I need a progress note template"
- "How do I document this treatment plan?"
- "What should I include in session documentation?"
Template Details
SOAP Notes (Standard Clinical Note Format)
Purpose: Systematic documentation of clinical encounters ensuring all essential elements are addressed.
Structure:
S - Subjective:
- Patient's reported symptoms, concerns, experiences
- Relevant quotes
- Changes since last session
- Current stressors
O - Objective:
- Observable behaviors
- Mental status examination findings
- Appearance, affect, speech, thought process
- Assessment scores (PHQ-9, GAD-7, etc.)
A - Assessment:
- Clinical impressions
- Progress toward goals
- Diagnosis (if applicable)
- Risk assessment summary
P - Plan:
- Interventions provided this session
- Homework/between-session activities
- Next session plan
- Any changes to treatment plan
- Safety planning if applicable
SOAP Writing Guide (Quick):
- S: Brief symptom summary in patient's words, changes since last session, stressors
- O: Mental status exam, observed behavior, validated scores (PHQ-9, GAD-7, etc.)
- A: Clinical impression, severity, risk assessment, progress toward goals
- P: Interventions delivered, homework, follow-up timing, safety plan if needed
Example (abbreviated SOAP):
S: "I've been less anxious this week but still waking at 3am."
O: MSE WNL, GAD-7 = 11 (moderate), PHQ-9 = 8 (mild)
A: Moderate anxiety with partial response; no SI/HI; risk low
P: CBT worry time, sleep hygiene plan, follow-up in 2 weeks
Progress Note Formats
DAP Notes (Data, Assessment, Plan):
- D - Data: Combines subjective and objective information
- A - Assessment: Clinical impressions and progress
- P - Plan: Interventions and next steps
BIRP Notes (Behavior, Intervention, Response, Plan):
- B - Behavior: Observed client behaviors and presentation
- I - Intervention: What the clinician did/provided
- R - Response: Client's response to interventions
- P - Plan: Future direction
GIRP Notes (Goals, Intervention, Response, Plan):
- G - Goals: Which treatment goals were addressed
- I - Intervention: Techniques/modalities used
- R - Response: Client's engagement and response
- P - Plan: Next steps and homework
Brief Examples:
DAP Example:
D: Reports panic episodes 2x this week; sleep 5-6 hours; GAD-7=13
A: Moderate anxiety with persistent impairment; risk low
P: Continue CBT, add interoceptive exposure; follow-up in 1 week
BIRP Example:
B: Tearful, low energy, limited eye contact; PHQ-9=16
I: Behavioral activation and cognitive restructuring
R: Engaged, identified 2 pleasant activities
P: Activity schedule; check-in next week
GIRP Example:
G: Goal 1 - reduce avoidance behaviors
I: Exposure hierarchy planning
R: Patient agreed to first two steps
P: Practice exposure twice before next visit
Treatment Plan Documentation
Purpose: Formal documentation of treatment goals, objectives, interventions, and timeline.
Standard Components:
-
Identifying Information:
- Client demographics
- Diagnosis(es)
- Date of plan, review dates
-
Problem List:
- Presenting problems
- Prioritization
-
Goals:
- Long-term goals (SMART format)
- Measurable outcomes
-
Objectives:
- Short-term, specific steps toward goals
- Time-bound
-
Interventions:
- Evidence-based approaches
- Frequency and duration
- Modality (individual, group, family)
-
Progress Measures:
- How progress will be tracked
- Specific assessments or indicators
-
Review Schedule:
- When plan will be reviewed/updated
- Discharge criteria
Treatment Plan Template (Concise):
PROBLEM:
DIAGNOSIS:
GOAL:
OBJECTIVE 1:
Intervention:
Responsible:
Target Date:
OBJECTIVE 2:
Intervention:
Responsible:
Target Date:
MEASUREMENT:
REVIEW FREQUENCY:
Example (Condensed):
PROBLEM: Depressive symptoms with functional impairment
DIAGNOSIS: Major Depressive Disorder, Moderate
GOAL: PHQ-9 < 5 within 12 weeks
OBJECTIVE 1: 3 pleasurable activities/week by week 4
Intervention: Behavioral activation, weekly therapy
Responsible: Therapist
Target Date: [Date]
MEASUREMENT: PHQ-9 every 2-4 weeks
REVIEW FREQUENCY: Monthly
Documentation Best Practices
Best Practices (Expanded):
- Use objective, behaviorally anchored language
- Document clinical reasoning for key decisions
- Include patient agreement and response to interventions
- Record safety planning steps and resources provided
- Avoid copy-forward without updating details
- Maintain clear separation of facts vs. impressions
- Follow organization and payer documentation rules
See
docs/references/documentation-standards.md for extended guidance.
General Principles:
- Write clearly and concisely
- Use professional, non-judgmental language
- Document facts, not assumptions
- Include both strengths and concerns
- Date and sign all entries
- Correct errors properly (single line, initial, date)
What to Include:
- All safety assessments and interventions
- Informed consent discussions
- Consultation with other providers
- Changes to treatment plan
- Patient's response to treatment
- Reasons for clinical decisions
What to Avoid:
- Subjective judgments without supporting data
- Stigmatizing language
- Information not relevant to treatment
- Excessive detail about trauma narrative
- Legally problematic statements
- Copying/pasting without updating
Timeliness:
- Complete notes promptly (ideally same day)
- Follow agency/regulatory requirements
- Document safety concerns immediately
Safety Protocols
Documentation of safety concerns is critical:
Required Documentation for Safety Issues:
- Specific risk assessment findings
- Interventions implemented
- Patient's response
- Follow-up plan
- Consultation obtained
- Resources provided
Suicide Risk:
- Document C-SSRS or other formal assessment
- Ideation, intent, plan, means specifics
- Protective factors
- Safety plan created
- Level of care determination rationale
- Follow-up scheduled
Violence Risk:
- Threat specifics (target, timeline, means)
- Duty to warn/protect actions taken
- Consultation and supervision
- Law enforcement involvement if applicable
Child/Elder Abuse:
- Observations leading to suspicion
- Reporting actions taken
- Report date, time, agency
- Case number if available
Safety Documentation Protocols (Expanded):
- Record ideation, intent, plan, means, and recent behaviors
- Document protective factors and reasons for living
- Note consultations, supervision, or collateral contacts
- Include level-of-care decision rationale
- Document crisis resources provided and patient response
Limitations & Considerations
Documentation serves multiple purposes:
- Clinical communication and continuity
- Legal protection
- Regulatory compliance
- Quality improvement
- Reimbursement
Balance competing demands:
- Thoroughness vs. efficiency
- Detail vs. readability
- Compliance vs. clinical utility
- Privacy vs. necessary communication
Legal Considerations:
- Documentation can be subpoenaed
- Write assuming record could be read in court
- Follow "document defensibly" principle
- Know your jurisdiction's requirements
- Understand HIPAA and privacy regulations
Cultural Considerations:
- Avoid cultural assumptions
- Use patient's own language when quoting
- Note cultural factors affecting presentation
- Document cultural adaptations to treatment
- Recognize bias in interpretation
Electronic Health Records:
- Follow system-specific requirements
- Use templates thoughtfully (customize, don't just click)
- Maintain security/confidentiality
- Understand copy-forward risks
- Regular review of historical notes for accuracy
Additional Limitations and Considerations:
- Documentation requirements vary by jurisdiction and payer
- EHR templates can miss nuance; customize for the case
- Notes can be subpoenaed; write defensibly
- Balance thoroughness with privacy and minimum necessary principle
References
Documentation Standards:
- American Psychological Association. Record Keeping Guidelines. Am Psychol. 2007;62(9):993-1004.
- HIPAA Privacy Rule, 45 CFR Part 160 and Subparts A and E of Part 164
- State-specific licensure board requirements
Best Practices:
- Mitchell RW. Documentation in Counseling Records: An Overview of Ethical, Legal, and Clinical Issues. 4th ed. American Counseling Association; 2017.
- Wiger DE, Huntley DK. Essential Interviewing: A Programmed Approach to Effective Communication. Springer; 2020.
SOAP Note Format:
- Weed LL. Medical records that guide and teach. N Engl J Med. 1968;278(11):593-600.
Additional References:
Status: ✅ Implemented
Priority: LOW - Phase 3
Last Updated: 2026-02-03
