Behavioral Health Notes: Types, Formats, and Best Practices

As you are here, you must be starting your mental health practice or working to improve it, and writing behavioral health notes is an important aspect of that.

Therapists, counselors, and mental health practitioners must take these notes when they entertain a patient. These notes help practitioners in providing better service, stay compliant, and develop the required connection with patients.

If you don’t write these notes, you can only work with clients if you are a mnemonist. Otherwise, every time you see the client, you’ll need a recap and shake off your mind to get the details out and progress further.

Before going into much detail, let’s first understand its definition.

What’s Behavioral Health Notes?

Behavioral health notes are clinical records that practitioners document while providing patients with treatment. It contains the patient’s mental, emotional, and behavioral health status, treatment progress, and interventions.

These notes help healthcare providers track patient well-being, assess treatment’s effectiveness, and ensure high-quality care.

According to a study conducted by Psychiatric Services, 49% of patients felt in control of their healthcare due to behavioral health notes. The study also concluded that the notes helped 45% of participants build better trust in their practitioners.

This shows that these notes are exceptionally beneficial. Now, let’s have a deeper look at its importance.

Importance of Behavioral Health Notes

There are several benefits that you can get from documenting behavioral health notes. Some of them are stated here:

• Provide Better Care and Treatment: Mental health progress notes allow you to continuously track a client’s treatment without remembering all the details of every session, which is impossible. Your notes allow you to identify patterns in a client’s thoughts and feelings, which allows you to personalize the treatment and move it in the right direction. Overall, these notes will act as your guiding light in providing effective care.
• Remembering Patient Details: During a session, patients can mention multiple details that they have mentioned before but don’t remember and can’t relate to or understand the situation. Rather than wasting time asking the client to repeat the information, you can find the information from the therapy notes and get an instant understanding.
• Avoid Troubles in Reimbursement: therapy health notes act as proof of the service provided to the patient. Many insurance companies mandate submitting these notes to get reimbursement. And, even if they don’t, it’s always better to be on the safe side and ready to provide the details. You can read the complete guide to Insurance Credentialing to know more about this aspect.
• Unified Healthcare Service: When you take the therapy progress notes and store them in electronic health record (EHR) system, they can be easily shared with the other healthcare professionals whom your patient visits. It help them to check the mental health history, current treatment, and medication, and take an informed decision.
• Evidence in Lawsuits: If any of your patients files a complaint against you, therapy notes can be used as evidence stating the condition of your patient and the treatment you provided.

 

Types of Behavioral Health Notes

There are multiple types of behavioral health notes that practitioners need to document based on the stage of the treatment. These notes can be defined under five different types:

• Assessments: These notes are useful at the initial stage of the treatment when the therapist needs to learn about the clients, understand the medical condition, and form a treatment roadmap. The assessment can be done periodically as well to re-evaluate the condition and edit the roadmap accordingly.
• Psychotherapy Notes: Though these are optional behavioral therapy notes, it is important to document them for perform the treatment better. These notes contain sensitive information about the client’s behavior and must be kept private from the client to avoid their influence on the treatment.
• Progress Notes: These notes are the core notes, containing the details of the session, the client’s treatment, progress, etc. These should be stored in the EHR system and can be shared with relevant parties as and when needed. One must add the progress note during or immediately after the session to ensure the information is accurate and concise.
• Treatment Plan: Though the treatment information can be part of the assessment and progress notes, a dedicated document is recommended. It contains a roadmap starting from the current situation to the goal set during the initial assessment. It also contains general information about the client, the mental health history, and the timeline for the set goal.
• Discharge summary: After the treatment is completed and the goal is achieved, the clinician provides patients with a discharge summary containing the details of the treatment, the condition at the time of discharge, post-discharge instructions, and the follow-up plan.

Common Formats for Behavioral Health Notes

There are different formats for documenting behavioral health notes, such as SOAP, DAP, and BIRP. These formats are developed to record information in a logical and easy-to-comprehend manner. However, there’s no one “right” format to write the therapy notes. You can choose the one that fits your approach and client goals. If required, you can even mix different formats to create a suitable one.

For now, we will discuss the formats which are widely accepted and used.

SOAP Notes

SOAP is one of the widely used formats that’s adopted due to the flexibility it offers. It coves all the key areas of the treatment, making sure that even the minor details get accommodated.

• Subjective (S): It includes the clients’ own assessment of their feelings and behavior since the last visit or while taking the session.
• Objective (O): This includes the clinician’s objective assessment of a client’s behavior, appearance, or any other measurable data.
• Assessment (A): The therapist’s assessment must include the professional evaluation of the subjective and objective aspects to diagnose clients and severity of condition and how it has changed with sessions.
• Plan (P): As the name suggests, it includes the treatment plan as you move forward, the upcoming interventions, tasks, and thoughts to convey to the client.

DAP Notes

DAP format is somewhat similar to SOAP. It is much simplified as it combines subjective and objective aspects into one single category, “Data.”

• Data (D): It includes everything that has happened in a session, combining the subjective information conveyed by the client during the session and objective observations by the clinician.
• Assessment (A): It is similar to SOAP’s assessment. Under this aspect, the clinician conducts the assessment of the data category and concludes the client’s condition, changes in diagnosis, improvements, etc.
• Plan (P): The plan category is always the same in any format. It suggests the actions to be taken while moving forward in diagnosis.

BIRP Notes

BIRP format is a unique approach that allows documentation of much more detailed ones.

• Behavior (B): This is similar to the data stage, which includes the client’s subjective feelings and the therapist’s objective assessment, combined to define the client’s behavior.
• Intervention (I): This section documents the intervention or therapeutic action that the clinician takes during the session to improve the behavior of the client.
• Response (R): This category is used to document the patient’s response to the therapeutic treatment during the session. The response can be connected with the behavior of the next session to understand whether the intervention was helpful or requires certain changes before continuing.
• Plan (P): Plan is the same as it is SOAP and DAP formats. It helps you define the overall treatment plan by understanding the connection between behavior,  intervention, and response.

Best Practices in Behavioral Health Notes

Writing these health notes is an essential clinical skill. There are certain best practices a therapist must follow to ensure that the therapy progress notes are accurate, effective, and to the point.

• Document the notes while the therapy session is in progress or just after it ends while details are fresh in your memory, reducing the risk of missing essential information.
• Always stick to observable facts, and don’t let your personal opinion or assumption cause misjudgment.
• Follow a structured format such as SOAP (Subjective, Objective, Assessment, Plan) or DAP (Data, Assessment, Plan) to ensure consistency and clarity in the documentation.
• Ensure compliance with HIPAA and other legal guidelines by keeping the client’s details safe and secure.
• Use neutral tone in the documentation, free from jargon, slang, or emotionally charged wording to ensure professionalism.
• Always document treatment objectives and measurable goals in the plan. After every session mark the progress towards them.
• Keep the notes prepared for legal scrutiny by keeping the documentation well-defined, accurate, and professional as if they could be reviewed in court.

Write Better and Faster Behavioral Health Notes With DENmaar

Using DENmaar can significantly enhance the efficiency, accuracy, and security of health notes. Our tool streamlines the documentation process by providing structured templates, and automation, and ensures compliance.

With DENMaar, you can choose various formats such as SOAP, DAP, and BIRP to ensure consistency in note-taking along with enough customization to fit individual client needs.

Besides that, DENmaar ensures that all records are encrypted, securely stored, and meet legal compliance requirements such as HIPAA.

You can also improve the service by features such as follow-ups and reminders and provide clients with maximum benefits.

Closing

It is essential to effectively document behavioral health notes to provide quality care, ensure continuity, and maintain legal and ethical compliance. By understanding the various therapy note types, and formats (such as SOAP and DAP), and following best practices such as objectivity, timeliness, and confidentiality, therapists can create clear and useful records.

Leveraging technology, such as using DENmaar software, can further enhance efficiency and accuracy in note-taking. Well-documented notes support better client outcomes and build reputation and credibility.