Clinical template
Case Note Template
A case note records one mental-health or social-work contact: what was covered, what you observed, risk, what you did, and the next step. It is not a hospital discharge summary and it is not a clinic SOAP for a sore throat. DAP and session-style notes both work if risk and the plan are impossible to miss.
Blank case note
Counselling, psychology, social work, addictions, or psychiatry follow-up. If your team uses BIRP or SOAP, keep those headings but do not skip risk. Write as if covering crisis staff will read this at 21:00.
Case note (DAP)
Date / time / duration / modality (in-person, video, phone): Clinician / discipline: Location / program: Client: [initials, age] | Others present (consent to include them): D — Data Presenting focus this session (client words where useful): Mental status (appearance, affect, thought, cognition — pertinent): Risk: SI/HI, plan, intent, means, protective factors, change vs last visit: Substance use if relevant this contact: Collateral (who, with consent): A — Assessment Clinical impression this session (not a full reformulation every time): Risk formulation (low / some / high, and why): P — Plan Interventions this session (modality, homework): Safety plan changes / who was notified: Meds discussed (if in scope) / liaison with FP or psychiatry: Next appointment / missed-appointment plan: Referrals / forms:
Fictional clients
Examples are made-up. Case notes are personal health information. Extra caution applies before releasing psychotherapy process notes to insurers — that is a medical release decision, not a copy-paste from this template. Review generated notes before they enter the chart.
DAP, BIRP, and SOAP in mental health
DAP (Data, Assessment, Plan) fits therapy follow-ups: data is what was said and observed, assessment is your synthesis including risk, plan is homework and safety. BIRP (Behavior, Intervention, Response, Plan) emphasizes what you did in the room and how the client responded. SOAP is fine for a psychiatry med-check that includes an exam-style MSE in Objective. The dedicated SOAP page is written for general clinic encounters. Here the non-negotiables are risk, interventions, and a next step — not a 12-system ROS.
| Heading set | Fits | Still required |
|---|---|---|
| DAP | Counselling and social-work sessions | Risk line, even when low; plan with date |
| BIRP | Skills-based or behavioural sessions | The intervention named, not 'supportive therapy' alone |
| SOAP | Psychiatry follow-up with MSE and med changes | Do not hide SI only in Subjective if you acted on it — put the formulation in A and the actions in P |
Risk and what not to write
If you asked about suicide, write the answer, including 'denied SI, no plan, protective factors X.' If you did not ask and the presentation called for it, that gap is the note. Safety-plan changes, duty-to-protect notifications, and ED referrals belong in Plan with times and names. Do not paste a full trauma narrative the client would not want in an insurer file; record that trauma was discussed, the themes needed for care, and store process detail per your college's guidance.
- Quote the client when the wording is the clinical fact ('I don't want to be here anymore') rather than paraphrasing into nothing.
- Name the modality (CBT thought record, MI, behavioural activation) so the next clinician can continue it.
- Missed sessions: attempt to contact, risk implication, and whether you will close the file.
- Do not document another family member's health in identifiable detail without a purpose.
Example 1 — counselling follow-up, DAP
Registered social worker, community clinic
29-year-old, Winnipeg. Video, 50 minutes. Fictional.
2026-08-26 10:00–10:50 video. RSW K. Desjardins. Client J.M., 29F. Alone, consented to video. Session 6 of 12. D Focus: 'I froze in the meeting again and went home.' Tearful then angry. Sleep 5 h, appetite ok. Alcohol 2 drinks Friday, no binge. Denied SI/HI; no plan or intent; last passive SI 2025, none this month. Protective: dog, sister in the city, next session booked. MSE: dressed, eye contact on video, speech normal, no psychosis, concentration subjectively poor this week. A Adjustment with anxious features, work trigger. Risk low today, unchanged. Avoidance of meetings is maintaining the anxiety. P Intervention: mapped the freeze (thought 'they'll see I'm useless' → leave). Homework: stay for 10 min of tomorrow's standup, one grounding skill practised in session. Safety plan unchanged; crisis line numbers already in her phone. FP not contacted (no meds, no risk change). Next: 2026-09-02 10:00 video. If she no-shows, call same day given last month's pattern.
Example 2 — psychiatry med-check, SOAP-style case note
Outpatient psychiatry
44-year-old, Victoria. 20-minute follow-up. Fictional.
2026-08-26. Dr. I. Rahman. In-person. Client A.P., 44M. GAD / previous MDD. No collateral. S Here for sertraline review. Worry still daily but less morning dread. Sleep improved from 4 h to 6 h. No panic this fortnight. Adherent. Denied SI, HI, psychotic symptoms. No new mixed features. Alcohol none. Work attending. O MSE: casual dress, restricted then brighter affect when talking about the dog, linear, no SI, cognition grossly intact. BP 126/78, HR 72 (clinic). Weight 81 kg stable. A 1. GAD — partial response to sertraline 100 mg, 8 weeks. 2. Remote MDD — no current MDE. 3. Risk low. P Increase sertraline to 150 mg daily, counsel activation and sexual side effects, 4-week supply. RTC 4 weeks or sooner if SI or akathisia. CBT wait-list already on; continue. Note to FP. Not a psychotherapy process note — med-check only.
Example 3 — brief crisis addendum
Same-day phone contact
Addictions counsellor, Thunder Bay. Fictional.
2026-08-26 16:40 phone 12 min. Client C.L. called after a lapse (2 days alcohol) following 3 weeks abstinence. Denied SI. No withdrawal tremor per self-report. Plan: attend tomorrow 09:00 group; if tremor/vomiting/sweats tonight → ED, not wait for group. Notified none (no consent to call partner; no imminent risk). Charted same day.
Draft the case note after the session
Scribeberry can generate DAP, BIRP, or SOAP-style mental-health notes from the session or from dictation. You still edit risk language before signing. Smart Push into Accuro, OSCAR, Jane, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
What is a case note in mental health?
The chart record of one contact: session content at a level needed for care, mental status, risk, interventions, and plan. Social work, counselling, psychology, addictions, and psychiatry all write case notes; headings differ, risk does not.
Should mental health notes use SOAP or DAP?
Either. DAP is common for therapy. SOAP fits med-checks. BIRP fits skills sessions. Choose the team's standard so covering clinicians can scan risk and plan without translating a new format each visit.
How much detail should a case note include?
Enough that another clinician can continue care and defend the risk decision. Not a transcript. Be careful with graphic trauma detail that is not required for treatment, especially if notes may later be released with consent.
Can Scribeberry write mental health case notes?
Yes. Use a DAP, BIRP, or psychiatry template, record or dictate, and generate. Review risk, safety-plan, and confidentiality wording before the note is saved. Custom templates can match program headings.
Templates
