Standard Note Types
These formats come built into AutoNotes and can be used immediately:
SOAP Note
A structured note documenting subjective reports, objective observations, assessment, and treatment plan.
DAP Note
A concise alternative to SOAP that includes Data, Assessment, and Plan.
BIRP Note
Focuses on Behavior, Intervention, Response, and Plan.
PIR / PIE Note
Problem, Intervention, and Evaluation — a brief, outcomes-focused note.
Narrative Note
A freeform note style with flexible, unstructured text.
GIRP Note
Goal, Intervention, Response, Plan — emphasizes progress toward goals.
SIRP Note
Subjective / Objective session information, Interventions, Response, and Planning.
Intake Note
Captures client demographics, presenting issues, history, and immediate needs.
Biopsychosocial Assessment
A comprehensive assessment across biological, psychological, and social domains.
Psychiatric Evaluation
A structured evaluation including symptoms, diagnostic impressions, and risk assessment.
Discharge / Termination Summary
Documents outcomes, progress toward goals, risk status, and follow-up recommendations.
ADIME Note
Assessment, Diagnosis, Intervention, Monitoring, and Evaluation — often used in healthcare/nutrition contexts.
Treatment Plan
Outlines goals, measurable objectives, interventions, and target dates.
Choosing the Right Format
You should pick the format your:
Agency requires
Supervisor or documentation standards recommend
Workflow fits best
If you're unsure, SOAP, DAP, or Progress Notes are commonly accepted defaults.
You can also generate multiple note types at once on the Finalize Session Details screen by selecting more than one format.
Custom Output Formats
If your practice uses a unique documentation structure, you can create your own format under:
Settings → Output Formats → Create Custom Output Format