Behavior

[Behavior narrative] (Capture the visit’s content in one coherent paragraph using the encounter’s natural flow. Include only details explicitly verbalized by the patient or clinician or directly observed and stated aloud. Include, if spoken: primary reason for today’s visit; onset/course since last visit; frequency, duration, severity; triggers/contexts; relieving or exacerbating factors; self-management attempts; concrete impact on functioning at home/work/school; associated symptoms only if mentioned; links to existing treatment goals only if referenced; the patient’s stated goals, motivation, barriers, and adherence to agreed home practice or medications only if mentioned; any safety concerns disclosed—e.g., suicidal or violent thoughts, access to means, recent crises, protective factors—using the patient’s wording when quoted; brief mental status elements explicitly described (appearance, behavior, speech, mood/affect, thought process/content, perception, cognition/orientation/attention, insight/judgment), emphasizing changes from prior baseline only if stated; standardized measure names and scores if stated; collateral facts or records if referenced; session context if stated—such as setting or telehealth method and who was present. Do not infer or solicit content not spoken.)

Intervention

(Record only what the clinician explicitly described doing during the visit. Use concise bullets in the order stated. Avoid modality-specific jargon unless said.)

[Techniques or strategies delivered] (Name the strategies or focus areas as stated. Examples if spoken: psychoeducation topics, skills practiced, problem-solving steps, coping or communication exercises.)
[In-session tasks completed] (Only if mentioned. Examples: worksheet reviewed, role-play conducted, relaxation practiced, exposure step attempted, values/goal clarification performed.)
[Risk mitigation actions] (Only if mentioned. Examples: safety planning elements, means-restriction counseling, crisis resources discussed.)
[Care coordination] (Only if mentioned. Examples: communication with another clinician, referral discussed, records reviewed and key points summarized.)
[Session context] (Only if mentioned. Examples: setting or telehealth method, privacy steps discussed, participants present.)

Response

[Response narrative] (Summarize the patient’s response to today’s interventions using only what was stated. Include, if spoken: engagement and participation; skills practiced and how the patient performed; perceived helpfulness or difficulties; barriers encountered; movement toward stated goals or objectives; change in symptoms or functioning compared with prior sessions; change in risk status if discussed. Use the patient’s wording when quoting. Do not add patient-reported data that was not spoken.)

Plan

(List only the clinician’s explicitly stated next steps. Use concise bullets in spoken order. Do not infer timing or content that was not said.)

[Next focus for treatment] (Only if stated. Example: topics or skill areas to address next session.)
[Between-session practice] (Only if stated. Include what to do and expected frequency/duration if spoken.)
[Risk management follow-up] (Only if stated. Example: check-ins, safety steps, crisis instructions.)
[Referrals or coordination] (Only if stated. Include purpose and any agreed actions.)
[Follow-up timing] (Only if stated. Example: return interval or contingencies.)
[Treatment plan updates] (Only if stated. Example: goal/objective refined, new objective added, or approach adjusted.)
[Medication considerations] (Only if stated. Example: continue as prescribed, side effects noted, coordinate with prescriber.)

(Do not infer or include any information not explicitly stated in the transcript. Leave sections blank if information is not available.)

Specialties

BIRP Note (Therapy)

Specialties

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