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Behavioral Health Therapist
15-20 minutes

Behavioral Intervention and Response Plan

The BIRP note template is an essential structured documentation tool for mental health professionals, designed to meticulously capture therapy sessions. Representing Behavior, Intervention, Response, and Plan, this framework facilitates comprehensive recording of patient interactions and therapeutic advancements. Ideal for clinicians aiming to document behavioral observations, therapeutic interventions, patient responses, and future treatment plans, the BIRP template, when integrated with s10.ai, the AI medical scribe, ensures precise and efficient note-taking. This enhances the quality of mental health care by effectively tracking patient progress and strategizing ongoing treatment plans.

2,444 uses
4.4/5.0
D
Dr. Emily Carter
Template Structure

Organized sections for comprehensive clinical documentation

Behavior:
• [describe patient's current behavior, mood, and affect] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
• [mention any observed changes in behavior] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
• [note any relevant behavioral incidents or episodes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Intervention:
• [describe therapeutic interventions used during the session] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
• [mention any specific techniques or strategies employed] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
• [note any medications administered or discussed] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
• [include a minimum of four interventions]
Response:
• [describe patient's response to the interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
• [mention any verbal or non-verbal feedback from the patient] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
• [note any changes in patient's behavior or mood following the intervention] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Plan:
• [outline the plan for future sessions or interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
• [mention any follow-up appointments or referrals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
• [note any homework or tasks assigned to the patient] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Stage of Change:
• [Identify client's stage of change: maintenance, action, preparation, contemplation, precontemplation]
Sample Clinical Note

Example of completed documentation using this template

Behavior:
- The patient appeared calm, displaying a stable mood and neutral affect. No notable behavioral changes were observed during the session. The patient mentioned a minor anxiety episode earlier in the week but effectively managed it with breathing exercises.
Intervention:
- Cognitive-behavioral therapy was utilized to address the patient's anxiety.
- Mindfulness techniques were introduced to assist the patient in managing stress.
- The patient was guided through a progressive muscle relaxation exercise.
- Discussed the potential benefits of initiating a low-dose SSRI medication, which the patient agreed to consider.
Response:
- The patient reacted positively to the interventions, expressing relief after the relaxation exercise.
- Verbally acknowledged the effectiveness of mindfulness techniques.
- Noted a slight mood improvement following the session.
Plan:
- Continue with weekly cognitive-behavioral therapy sessions.
- Schedule a follow-up appointment in two weeks to evaluate the effectiveness of the mindfulness techniques.
- Assign the patient daily mindfulness practice as homework.
Stage of Change:
- The patient is currently in the action stage, actively working on managing anxiety.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline the documentation process for healthcare professionals, ensuring accurate and efficient recording of patient behavior, interventions, responses, and future plans. By incorporating high-search healthcare and clinical keywords, this template enhances the visibility and accessibility of clinical notes, making it an invaluable tool for clinicians seeking to optimize patient care. The template allows for detailed documentation of therapeutic interventions, specific techniques, and any medications discussed, while also capturing patient responses and feedback. Additionally, it facilitates the planning of future sessions, follow-up appointments, and patient assignments, all while identifying the client's stage of change. Adopt this template to enhance your clinical documentation, improve patient outcomes, and stay ahead in the ever-evolving healthcare landscape.
Frequently Asked Questions

Common questions about this template and its usage

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