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TR BIRP Progress Note Checklist

The document is a checklist for progress notes used by counselors. It includes sections for documenting a client's behavior, the intervention, the client's response, and the treatment plan. The behavior section includes observing and quoting the client. The intervention section covers goals addressed and homework review. The response section notes the client's reaction to the session. The plan section outlines revisions needed and next steps. The general checklist ensures the note is complete, connected to the treatment plan, and understandable to anyone reading it.

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Ryan Cox
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2K views1 page

TR BIRP Progress Note Checklist

The document is a checklist for progress notes used by counselors. It includes sections for documenting a client's behavior, the intervention, the client's response, and the treatment plan. The behavior section includes observing and quoting the client. The intervention section covers goals addressed and homework review. The response section notes the client's reaction to the session. The plan section outlines revisions needed and next steps. The general checklist ensures the note is complete, connected to the treatment plan, and understandable to anyone reading it.

Uploaded by

Ryan Cox
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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B.I.R.P.

Progress Note Checklist


B Behavior

Counselor observation, client statements

Check if
addressed

1. Subjective data about the clientwhat are the clients observations, thoughts,
direct quotes?
2. Objective data about the clientwhat does the counselor observe during the
session (affect, mood, appearance)?

I Intervention

Counselors methods used to address goals and objectives, observations, client statements

1. What goals and objectives were addressed this session?


2. Was homework reviewed?
R Response

Clients response to the intervention, progress made toward Tx Plan goals and objectives

1. What is the clients current response to the clinicians intervention in the session?
2. Clients progress attending to goals and objectives outside of the session?
P Plan
Document what is going to happen next

1. What in the Tx Plan needs revision?


2. What is the clinician going to do next?
3. What is the next session date?

General Checklist
1. Does the note connect to the clients individualized treatment plan?
2. Are client strengths/limitations in achieving goals noted and considered?
3. Is the note dated, signed and legible?
4. Is the client 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 (eg. GAF, measures of functioning)?
7. Are all abbreviations standardized and consistent?
8. Did counselor/supervisor sign 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?

Check if
addressed

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