Progress Notes & Treatment Plans

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The intake note type encompasses key clinical information of the client and is an essential note for all clinical workflows. This note type tracks the provider’s first meeting with the client, and captures information that will inform evidence based workflows and any measurement based care strategies. This note type is crucial to therapy workflows as it includes information related to the client's presenting problems, symptoms that justify clinical diagnoses, relevant history (i.e. social, medical, family, medical, substance use, developmental), medical necessity, treatment plans as well as any clinical analysis of the client.

The intake note type is commonly used to document an initial intake with a client. It documents relevant clinical information in order for the provider to create treatment plans. Creating a complete and detailed intake note is an essential skill within the therapeutic toolkit, because that’s how future treatment is planned.

Intake documentation is a key part of a provider’s therapy workflow, and is an important first step when beginning treatment with a client. Intake progress notes are an essential part of evidence based pathways (and clinical pathways) and showcases how the provider conceptualizes the client’s case. Documenting clearly will also enhance progress note compliance, ensuring clinical quality. This note type is used by providers who are meeting with the client for an initial intake, and it can be used for individual, family, and couples sessions.

By using Blueprint’s AI Notetaker and toggling the “Intake Note” for the designated session, an Intake Note will be automatically generated immediately after the recorded session and output into a single Intake note section.

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The SOAP note type has 4 distinct sections: Subjective, Objective, Assessment and Plan. These sections are crucial to clinical workflows as it includes information related to the client's presentation, symptoms, interventions used by the provider, responses from the client, treatment plans, as well as any clinical analysis of the client.

This note type is often favored by providers because of its structure, making it easy for readers to see where information will be. It is also the most commonly used note type, so it is highly recognizable across providers of different disciplines, as well as for reviewers of clinical records. This can enable providers of cross disciplines to consult on different care pathways as well as on a client’s transition of care.

Documentation is a key part of a provider’s therapy workflow, and is crucial in highlighting tools used within measurement based care. Progress notes are an essential part of evidence based pathways (and clinical pathways) and showcases how the provider is helping the client reach their goals. Documenting clearly will also enhance progress note compliance, ensuring clinical quality. The SOAP note type is the most common note type within a provider’s therapeutic toolkit. used by behavioral health providers, including prescribing providers such as psychiatrists. This note type can be used for individual, group, family, and couples sessions.

By using Blueprint’s AI Notetaker, a SOAP note will be automatically generated immediately after your recorded session, outputting into the SOAP note format (4 sections).

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The BIRP note type has 4 distinct sections: Behavior, Intervention, Response, Plan. These sections are crucial to clinical workflows as it includes information related to the client's presentation, symptoms, interventions used by the provider, responses from the client, treatment plans, as well as any clinical analysis of the client.

This note type is similar to the SOAP note type where it is highly structured, but differs in the sense that it separates out what interventions were carried out and clearly details what the responses to those interventions are. The note starts off with documenting observable behaviors, and may be a good choice for providers who want to focus their documentation on the client’s behaviors, as well as showcase the interventions completed in session.

Documentation is a key part of a provider’s therapy workflow, and is crucial in highlighting tools used within measurement based care. Progress notes are an essential part of evidence based pathways (and clinical pathways) and showcases how the provider is helping the client reach their goals. Documenting clearly will also enhance progress note compliance, ensuring clinical quality. This note type is commonly used by providers who want to document the observable behaviors of the client in their clinical documentation. This note type can be used for individual, group, family, and couples sessions, and because of its focus on behaviors, it would be especially helpful for individual, couples and family sessions so the note can capture behavioral dynamics between clients in the session.

By using Blueprint’s AI Notetaker, a BIRP note will be automatically generated immediately after your recorded session, outputting into the BIRP note format (4 sections).

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The DAP note type has 3 sections: Data, Assessment and Plan. These sections are crucial to clinical workflows as it includes information related to the client's presentation, symptoms, interventions used by the provider, responses from the client, treatment plans, as well as any clinical analysis of the client.

This note type is a little more condensed and a little more narrative. This is a great one to use for providers who want their documentation to be more free flowing and follow the natural discourse of a session. Since the Data (D) section captures all available data, assessment data can seamlessly be plugged into this note type.

Documentation is a key part of a provider’s therapy workflow, and is crucial in highlighting tools used within measurement based care. Progress notes are an essential part of evidence based pathways (and clinical pathways) and showcases how the provider is helping the client reach their goals. Documenting clearly will also enhance progress note compliance, ensuring clinical quality. This note type is commonly used by providers who may also have a lot of assessment data and data points to incorporate into their documentation, for example, when using digital therapy worksheets or digital therapy homework. Having a section that consolidates all data may be helpful for these scenarios. In terms of session settings, this note type can be used for individual, group, family, and couples sessions, and may be most helpful in individual settings when there are a lot of assessment data.

By using Blueprint’s AI Notetaker, a DAP note will be automatically generated immediately after your recorded session, outputting into the DAP note format (3 sections).

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The GIRP note type has 4 sections: Goal, Interventions, Response, and Plan. These sections are crucial to clinical workflows as it includes information related to the client's presentation, symptoms, interventions used by the provider, responses from the client, treatment plans, as well as any clinical analysis of the client.

This note type starts off with the client’s treatment goals and objectives, making it highly client centered as it focuses on the client’s reasons and motivations for treatment. Like BIRP notes, it separates out the interventions and responses, thereby capturing what specifically was done in the session to target the treatment goals and objectives.

Documentation is a key part of a provider’s therapy workflow, and is crucial in highlighting tools used within measurement based care. Progress notes are an essential part of evidence based pathways (and clinical pathways) and showcases how the provider is helping the client reach their goals. Documenting clearly will also enhance progress note compliance, ensuring clinical quality. This note type is commonly used by community mental health agencies because it clearly outlines how the interventions used in session directly tie in with the treatment goals for the client. This note type can be used for individual, group, family, and couples sessions, as long as the goal section is tailored to the specific setting.

By using Blueprint’s AI Notetaker, a GIRP note will be automatically generated immediately after your recorded session, outputting into the GIRP note format (4 sections).

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The EMDR note type has multiple sections, and most commonly include: Presenting Issue or Memory, Image, Negative Cognition, Positive Cognition, Validity of Cognition, Emotions, SUDs, Location of Body Sensation, and Desensitization. These sections are crucial to clinical workflows as it includes information related to the client’s presenting problems, mental images related to the issue, beliefs (negative and positive) around the issue, distress levels, bodily sensations around the issue and client responses around resolutions.

This note type is highly specific to the modality, and is detailed in the clinical information it captures, making it easy for cross disciplinary providers to access the relevant clinical information. Providers using this modality should use this note type so they can accurately track client’s progress throughout EMDR treatment.

By using Blueprint’s AI Notetaker, an EMDR note will be automatically generated immediately after your recorded session, outputting into the EMDR note format (9 sections).

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The case management note type encompasses many different services within the care pathway. This note type can be used to document clinical case management, medication case management, and more. The case management note type most commonly includes information related to: the reasons the services are being provided, what services are being provided/linked to, the responses from the client, and what follow up plans there may be.

Case management is a key tool within the therapeutic toolkit and is essential in servicing the whole person. This note type helps the provider accurately capture all the services that are provided to the client, as well as justifying why these services are provided. Since these services are often ancillary services, ensuring they are completely documented will enhance progress note compliance and thereby increase clinical quality.

Documentation is an important part of a provider’s therapy workflow, and is crucial in highlighting all the services provided to the client. This note type is commonly used by providers who meet with clients to provide case management, such as referral and linking clients to resources and helping clients manage their care. This note type can be used for individual, group, family, and couples sessions, and may be most helpful in individual settings when the provider is working 1:1 with a client on linkages to services.

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The SIRP note type is structured into four sections: Situation, Intervention, Response, and Plan. The Situation section includes the client's presenting issues, clinician observations, and the intervention setting. The Intervention section details the tools used by the clinician to address these issues. The Response section records the client's reactions and progress toward treatment goals. Finally, the Plan section outlines next steps and adjustments in the treatment plan.

SIRP notes enhance documentation quality by covering all critical aspects of client care in a systematic manner. This format allows for effective tracking of client progress, and helps clinicians maintain comprehensive, organized, and accurate records, leading to better clinical outcomes.

SIRP notes are versatile and can be used in various therapeutic settings, including individual, couples, family, and specialized therapy sessions. They are applicable in community mental health centers, hospitals, outpatient clinics, and educational environments, providing consistent and detailed documentation across different healthcare contexts.

With Blueprint’s AI Notetaker, a SIRP note is automatically generated after your recorded session, complete with all four sections: Situation, Intervention, Response, and Plan. This automation streamlines documentation, allowing clinicians to concentrate on client care while ensuring high-quality clinical records.

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The PIE note type is organized into three sections: Problem, Intervention, and Evaluation. The Problem section identifies the client's issues and functional impairments. The Intervention section details the therapeutic techniques and strategies used, and the Evaluation section assesses the client's responsiveness, noting progress, challenges, and next steps.

The PIE note format is brief and clear, making it time-efficient for clinicians. It allows for quick and effective documentation of essential session aspects, ensuring clarity in the client's problems and the clinician's interventions. Even with its concise nature, the note demonstrates medical necessity, and is ideal for fast-paced clinical environments where swift yet thorough documentation is needed.

PIE notes are versatile and suitable for individual, group, family, and couples therapy sessions. They provide a clear way to document immediate problems, interventions, and responses, making them particularly useful in high-demand settings like community mental health clinics, outpatient services, and schools.

Using Blueprint's AI Notetaker, PIE notes can be automatically generated after your recorded session. The AI ensures accurate and efficient documentation of the Problem, Intervention, and Evaluation sections, reducing administrative workload and allowing clinicians to focus on client care.

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The PIRP note type is structured into four key sections: Problem, Intervention, Response, and Plan. The Problem section focuses on the client's presenting problem and documents the client's current complaints, symptoms, and conditions in behavioral terms. It includes an assessment of the client's status and the necessity of the session. The Intervention section outlines the interventions the provider uses during the session. The Response section details the responses the client has to those interventions and the Plan section discusses the client’s plan of treatment.

PIRP notes start with the client's presenting problem, making it easier to document and address specific issues in each session. By separating interventions and responses, PIRP notes provide a clear record of what was done in the session and how the client responded, which can be crucial for tracking progress and adjusting treatment plans. The structured format of PIRP notes can make them quicker to write, which is beneficial for busy clinicians who need to document sessions efficiently.

PIRP notes are versatile and can be used in various therapeutic settings, including individual, group, family, and couples therapy. They are particularly useful in community mental health settings where clear and concise documentation is crucial for continuity of care. The problem-focused nature of PIRP notes makes them suitable for short-term and long-term therapy, as well as for clients with specific, identifiable issues.

By utilizing Blueprint’s AI Notetaker, PIRP notes can be automatically generated immediately after your recorded session. The AI will output the notes in the PIRP format, ensuring that all four sections—Problem, Intervention, Response, and Plan—are accurately documented.

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The Couples SOAP note type has 4 distinct sections: Subjective, Objective, Assessment, and Plan. These sections are crucial in couples therapy as they provide a structured format to document the couple's interactions, presenting concerns, interventions used, responses from each partner, treatment plans, and any clinical analysis of their relationship dynamics.

This note type clearly documents the couples’ process in treatment, and is also a highly recognizable format across different clinical disciplines. Additionally, Blueprint generates 3 distinct notes, so you as the provider have the freedom to choose which note you want to use for billing. Blueprint generates 1 note for each client, treating each as the primary client by documenting their functional impairments and symptoms, and an additional process-oriented note for the couple, highlighting joint progress and relational dynamics.

Couples SOAP notes are used in documenting treatment of two people in a partnership or relationship, so that the provider can document how interventions enhance their relational dynamics. Recording how the primary client’s symptoms are alleviated through treatment, alongside improvements in the couple’s overall functioning, is essential. The SOAP note type is an indispensable tool in a therapist’s toolkit, widely applied in individual, group, family, and couples sessions.

By using Blueprint’s AI Notetaker, a Couples SOAP note will be automatically generated immediately after your recorded session, outputting into the Couples SOAP note format (4 sections). Blueprint's AI enhances this process by generating three distinct notes—one for each partner and a process-oriented note for the couple—giving therapists the flexibility to bill effectively for the primary client and maintain comprehensive records.

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The Psychiatric Initial Evaluation is a comprehensive and structured note used by prescribers like psychiatrists or Nurse Practitioners during the initial assessment of a patient. The note encompasses multiple sections: Identifying Information, Chief Complaint, History of Present Illness (HPI), Psychiatric Review of Systems, Risk Assessment, History (including Psychiatric, Family, Medical, and Social History), Current Medications, Allergies, Vital Signs, Mental Status Exam, Assessment, Diagnosis, and Plan of Treatment. These sections collectively provide an in-depth overview of the patient's mental, emotional, and physical health, offering a holistic understanding essential for accurate diagnosis and personalized treatment planning.

The Psychiatric Initial Evaluation offers a detailed and methodical approach to patient assessment, ensuring no aspect of a patient's history or current condition is overlooked. It's structured format enhances clarity and organization, making it easier for prescribers to compile comprehensive and meticulous notes. The detailed nature of the evaluation not only supports medical necessity but also ensures that the specific needs of each patient are addressed. Moreover, the thorough documentation required in initial evaluations aids in compliance with insurance and regulatory standards, ensuring that the prescriber’s interventions are justified and reimbursed timely.

This note type is used in diverse psychiatric settings, including private practices, hospitals, mental health clinics, and community health centers. Initial Evaluation notes are particularly valuable during initial consultations, laying the groundwork for ongoing psychiatric care and treatment. They facilitate seamless transitions between different healthcare providers, ensuring continuity and consistency in patient care. Given its comprehensive nature, the initial evaluation is instrumental not only in individual patient assessments but also in multidisciplinary team discussions, allowing for a collaborative approach to treatment planning.

Utilizing Blueprint’s AI Notetaker, a Psychiatric Initial Evaluation note can be automatically generated shortly after a recorded session. The AI technology meticulously organizes the session's information into the PIE note format, ensuring completeness and accuracy. This automation not only saves valuable time for the prescriber but also enhances the precision and thoroughness of the documentation, thereby supporting effective clinical decision-making and optimized patient outcomes.

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The Psychiatric Follow-Up Note is a key document used by prescribers to track continuity of care and progress during follow-up sessions. It includes several critical sections: Chief Complaint(s), Psychiatric Review of Systems, History of Present Illness (HPI), Allergies, Mental Status Exam, Vital Signs, Assessment, Risk Assessment, Therapeutic Interventions (if applicable), Current Medications, and Plan.This well-structured note type allows prescribers to comprehensively track a patient's evolving mental health symptoms, their response to treatments, and any new symptoms or concerns that emerge between visits, facilitating a holistic and ongoing care approach.

The Psychiatric Follow-Up Note offers a consistent framework for documenting patient progress, ensuring that all relevant aspects of their health are thoroughly assessed It provides a clear, systematic approach, ensuring each follow-up session builds on the previous ones. This enhances the clarity and precision of ongoing treatment documentation, serving as a reliable reference to evaluate the efficacy of current treatment plans and make necessary adjustments. Moreover, it supports compliance with insurance and regulatory requirements by providing thoroughly detailed evidence of medical necessity. When there is an added therapeutic component, this note type also captures specific interventions provided, justifying the extended session time and supporting billing practices.

The Psychiatric Follow-Up Note is essential in various clinical settings, including private practices, hospitals, mental health clinics, and community health centers. It is particularly useful during follow-up sessions where ongoing patient monitoring and treatment adjustments are required. This structured note type also facilitates communication among multidisciplinary teams by clearly articulating a patient's health statuses across different domains and thus promotes long term positive health outcomes.

Harnessing Blueprint’s AI Notetaker, a Psychiatric Follow-Up Note can be automatically produced shortly after a recorded session. The AI meticulously organizes and summarizes the session’s information into the follow-up note format, ensuring that all critical areas are addressed. This automation significantly reduces the time and effort required by the prescriber to document patient interactions, enhancing note accuracy and completeness. The AI-driven documentation assures that prescribers meet regulatory and insurance requirements efficiently, allowing them to focus more on patient care and less on administrative tasks.

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Custom notes can be made to whatever your needs are! Different organizations have different needs and different external regulators. The content of custom notes are handcrafted to your specific requirements. This can include as many sections as you require, and can be tailored to heighten whatever aspects of the note you desire.

This custom note type is made specifically for your organization, and aligns with what you need to see in your documentation. You have the ability to detail what each section needs to include, so that you can meet your specific set of requirements.

This custom note type is crafted to your specific needs, so whatever setting you would want to use this custom note type in, is the type of setting that can be done.

By using Blueprint’s AI Notetaker, a custom note will be automatically generated immediately after your recorded session, outputting into a custom note format of your choice. Blueprint's AI enhances this process by generating a note to your exact requirements - giving therapists the flexibility to target their specific set of needs and maintain comprehensive records.

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Focus on your clients. Leave the documentation to us.

Trusted by over 20,000 mental health professionals across thousands of organizations

It's never been easier to complete progress notes and treatment plans on time

Get high-quality, personalized notes with Blueprint’s industry-leading features

Use Blueprint directly on top of your EHR

Get back 5 to 10 hours back each week so you finally have time to...

Enterprise-grade security and privacy

Our mission is to build AI-assisted products to enable therapist-powered care

Trusted by over 20,000 mental health professionals  across thousands of organizations