The Complete Guide to Progress Notes
Master clinical documentation with our comprehensive guide to progress notes. Learn the differences between SOAP, DAP, BIRP, and GIRP formats, with examples and best practices for 2026.
What Are Progress Notes?
Progress notes are clinical documents that record patient encounters on a session-by-session basis. They track how patients improve, respond to treatment, and document any changes to the care plan. Progress notes serve three critical functions in healthcare:
- Legal documentation: Creates a permanent record of care provided
- Clinical communication: Enables care coordination between providers
- Billing support: Justifies medical necessity for reimbursement
Key Fact: Physicians spend an average of 15 hours per week on documentation—time that could be spent with patients. AI medical scribes can reduce this burden by up to 80%.
Types of Progress Notes
Different clinical settings require different documentation formats. Here are the four most common types of progress notes used in healthcare.
Visual comparison of the four main progress note formats
SOAP Notes
Subjective, Objective, Assessment, Plan
The gold standard for clinical documentation, used across all medical specialties.
Example SOAP Notes
S: 42-year-old male presents with 3 days of persistent cough, mild fever (100.4°F at home), and fatigue. Denies shortness of breath or chest pain. No sick contacts. O: Vitals: T 99.8°F, BP 128/82, HR 78, RR 16, SpO2 98% RA. Lungs: scattered rhonchi bilaterally, no wheezes. Pharynx mildly erythematous. A: Acute bronchitis (J20.9) P: 1. Supportive care with rest and fluids 2. Guaifenesin 400mg PO Q4H PRN 3. Return if worsening symptoms or not improved in 5-7 days
DAP Notes
Data, Assessment, Plan
Streamlined format that combines subjective and objective data into a single section.
Example DAP Notes
D: Client reported continued anxiety related to work stress. Appears more relaxed than previous session. PHQ-9 score improved from 14 to 10. Practicing breathing exercises daily as assigned. A: Generalized anxiety disorder showing improvement with current treatment approach. Client demonstrating good engagement with coping strategies. P: Continue weekly CBT sessions. Introduce progressive muscle relaxation. Review medication efficacy at next appointment.
BIRP Notes
Behavior, Intervention, Response, Plan
Focuses on client behavior and response to therapeutic interventions.
Example BIRP Notes
B: Client presented with flat affect and reported difficulty sleeping. Made minimal eye contact initially. Disclosed increased alcohol use over past week. I: Utilized motivational interviewing to explore ambivalence about alcohol use. Reviewed harm reduction strategies. Practiced mindfulness grounding exercise together. R: Client became more engaged during MI discussion. Acknowledged connection between alcohol use and sleep issues. Completed grounding exercise successfully. P: Continue MI approach. Assign sleep hygiene handout. Consider psychiatry referral for medication evaluation.
GIRP Notes
Goal, Intervention, Response, Plan
Goal-oriented format that tracks progress toward specific treatment objectives.
Example GIRP Notes
G: Client will develop three healthy coping strategies to manage anger by end of month (Treatment Goal #2). I: Reviewed triggers identified last session. Introduced cognitive restructuring technique. Role-played using "I" statements in conflict scenarios. R: Client successfully identified 3 automatic negative thoughts. Demonstrated ability to reframe one thought with support. Expressed interest in practicing "I" statements. P: Practice cognitive restructuring with worksheet. Apply "I" statements in one real situation before next session. Review progress on goal next week.
Which Format Should You Use?
Choose the right progress note format based on your specialty and documentation needs.
| Format | Best For | Key Focus | Complexity |
|---|---|---|---|
| SOAP | Medical practices, hospitals, primary care | Comprehensive clinical picture | Medium |
| DAP | Mental health, high-volume settings | Streamlined documentation | Low |
| BIRP | Behavioral health, therapy, counseling | Behavior and interventions | Medium |
| GIRP | Social work, case management, ACT | Goal-oriented progress | Medium |
Compliance Requirements for 2026
Stay compliant with healthcare documentation standards and regulations.
Medicare Documentation
Progress notes required at or before every 10th session to demonstrate medical necessity.
HIPAA Compliance
All notes must protect patient privacy while containing sufficient clinical information.
Timeliness
Best practice is to complete documentation within 24-72 hours of the encounter.
Medical Necessity
Notes must justify ongoing care and support billing with adequate clinical detail.
Best Practices for Progress Notes
Follow these guidelines to write effective, compliant progress notes.
Be Specific and Objective
Use measurable observations and specific details rather than vague statements.
Avoid Note Bloat
Focus on relevant, medically necessary information. Avoid excessive copy-paste.
Use Standard Terminology
Stick to accepted medical terminology and abbreviations for clarity.
Document Critical Information
Thoroughly document safety concerns, suicidal ideation, and high-risk situations.
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Frequently Asked Questions
What is a progress note in healthcare?
A progress note is a clinical document that records patient encounters, treatment progress, and care plans. It serves as a legal record, communication tool between providers, and supports billing documentation. Common formats include SOAP, DAP, BIRP, and GIRP notes.
What is the difference between SOAP notes and progress notes?
SOAP notes are a type of progress note. Progress notes is the broader category that includes multiple formats like SOAP (Subjective, Objective, Assessment, Plan), DAP (Data, Assessment, Plan), BIRP (Behavior, Intervention, Response, Plan), and GIRP (Goal, Intervention, Response, Plan). SOAP is the most widely used format in medical settings.
How often should progress notes be written?
Progress notes should be written after every patient encounter. For Medicare patients, progress notes are required at or before every 10th session. Best practice is to complete documentation within 24-72 hours of the encounter to ensure accuracy and compliance.
What should be included in a progress note?
A progress note should include: patient identification, date and time of encounter, chief complaint or reason for visit, relevant clinical findings, assessment or diagnosis, treatment plan, and provider signature. The specific sections depend on the format used (SOAP, DAP, BIRP, or GIRP).
Can AI help write progress notes?
Yes, AI medical scribes like PatientNotes can automatically generate progress notes by listening to patient encounters. AI scribes save clinicians an average of 2+ hours per day on documentation while maintaining accuracy and compliance. The AI captures the conversation and generates properly formatted notes for review.