BIRP Note Template

Use the BIRP Note Template as a checklist to follow best practices when documenting client progress and treatment plans, ticking all essential questions.

Download as free PDF

Library
Healthcare
BIRP Note Template

BIRP Note Template

Behavior - Counselor Observation, Client Statements

Counsellor's Methods Used To Address Goals And Objectives, Observations, Client Statements

Client's Response To The Intervention, Progress Made Toward Tx Plan Goals And Objectives

Document What Is Going To Happen Next

General

Is this sample what you are looking for?
Sign up to use & customise this template, or create your own custom checklist:

Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

Easy inspection app for your digital checklists

Conduct inspections anytime, anywhere - even offline
Capture photos as proof of compliance or areas needing attention
Instantly generate and share detailed reports after the inspections
Assign & track follow-up tasks, view historical trends on a centralized dashboard

BIRP Note Template

Use the BIRP Note Template as a checklist to follow best practices when documenting client progress and treatment plans, ticking all essential questions.

1. Subjective data about the client—what are the client's observations, thoughts, and direct quotes?

2. Objective data about the client—what does the counselor observe during the session (affect, mood, appearance)?

1. What goals and objectives were addressed in this session?

2. Was homework reviewed?

1. What is the client's current response to the clinician's intervention in the session?

2. What is the client’s progress attending to goals and objectives outside of the session?

1. What in the Tx Plan needs revision?

2. What is the clinician going to do next?

3. What is the next session date?

1. Does the note connect to the client's individualized treatment plan?

2. Are client strengths/limitations in achieving goals noted and considered?

3. Is the note dated, signed, and legible?

4. Are the client’s name and/or identifier included on each page?

5. Has referral and collateral information been documented?

6. Does the note reflect changes in client status (e.g., GAF, measures of functioning)?

7. Are all abbreviations standardized and consistent?

8. Did the counselor/supervisor sign the note?

9. Would someone not familiar with this case be able to read this note and understand exactly what has occurred in treatment?

10. Are any non-routine calls, missed sessions, or professional consultations regarding this case documented?