Therapists, social workers, counselors, MSW students
Clinical documentation
The session ends. The note still has to get written, and it has to say what happened in words a reviewer accepts.
These guides give you formats, phrases and word banks to keep beside you while you write.
Toolkit
Single guides
- SOAP, DAP, BIRP, GIRP Note Formats at a Glance + Abbreviations$5
- Subjective (S) Phrase Guide: Reporting Verbs, Quoting, 14 Stems$6
- Mental Status Exam & Objective Language Guide$5
- Risk & Safety Documentation Phrase Guide$6
- Biopsychosocial Assessment Language Guide$6
- Assessment & Plan Writing Guide: Medical Necessity, Progress, Plan Checklist$6
- Interventions by Modality Phrase Bank$6
- Client Response & Progress Language$4
- Informal-to-Clinical Swap List$4
- Clinical Documentation Word Bank: Verbs, Adjectives, Nouns, Qualifiers, Connectors$6
- Change & Interaction Language for Progress Notes$6
Please note
This guide supports, and does not replace, your agency policy, payer requirements, licensing board rules, and clinical supervision.
The guide offers wording options for documentation. It is not legal, billing, coding or clinical advice, and it does not guarantee that any note will meet a payer's, agency's or board's requirements. The worked example uses a fictional composite client; no real client information appears anywhere in the files.
Buying for a team or several units? See licences for teams and organizations.