Progress notes: SOAP, DAP, BIRP and treatment plans

This lesson covers the three progress note formats most clinicians learn, SOAP, DAP and BIRP, what a treatment plan usually holds, and then the part that is binding: what Oregon's licensing boards require in a client record, how long it must be kept, and what the Professional Disclosure Statement must contain now that the Board no longer approves it. If you are in a graduate program or your first year of Oregon practice and want to know which documentation habits are convention and which are rule, this lesson sorts them.

Format is convention; content is rule

None of the three Oregon boards covered here names a note format; OBLPCT's rule requires progress notes and says nothing about SOAP. The acronyms come from training programs, EHR vendors and managed-care settings, and vendor explainers such as ICANotes agree that the choice matters less than using one consistently. Learn one, and keep the board's minimums in view.

SOAP, DAP and BIRP

SOAP

Subjective, Objective, Assessment, Plan. The client's report in their own terms; what you observed, such as affect, presentation and anything measurable; your clinical read of the session against the treatment plan; and what happens next. It is the most widely taught format.

DAP

Data, Assessment, Plan. DAP folds the subjective and objective material into one Data section, which suits therapy sessions where the line between what the client said and what you observed is thin. Assessment and Plan work as they do in SOAP.

BIRP

Behavior, Intervention, Response, Plan. BIRP is organized around what you did: the client's presenting behavior, the intervention you used, how the client responded, and the plan. It is common in behavioral health agencies and managed-care settings, where a reviewer wants the intervention tied to a response. The note template attached to this lesson lays out both.

What belongs in every note, whatever the letters

The APA's Record Keeping Guidelines, published in 2007 and still current, list for each substantive contact the date and duration of the session, the type of service, the nature of the intervention, and a formal or informal assessment of the client's status. Those four fit any format. Oregon's boards add timing: OBLPCT's rule says client records "should be recorded concurrently with the services provided", and the social work board's rule uses the same phrase. The diagnosis recorded here is also what goes on a superbill.

What Oregon actually requires in the record

LPCs, LMFTs and registered associates: OAR 833-075-0070

OAR 833-075-0070, last amended and effective August 12, 2026, applies to licensees, registered associates, and anyone on a limited permit or temporary practice authorization. The record must include, at minimum, a formal or informal assessment of the client, counseling goals or objectives, and progress notes of sessions. It must be legible, kept in a "secure, safe, and retrievable condition", and retained for at least seven years from the date of last service. Section (5), in the rule as amended, says the seven years run from the last date of service by the treating provider, whether the record sits with that provider or with a custodian of record under OAR 833-075-0080.

You must notify the Board if client records are destroyed or lost, and you may not withhold records a client requests solely because payment has not been received.

Social workers in private practice: OAR 877-030-0100

OAR 877-030-0100 applies to a regulated social worker who serves clients outside an agency setting. The minimum record is an assessment, a treatment or intervention plan, and progress notes, all recorded concurrently. Retention is seven years from the date of the last session. A social worker in private practice must also name a qualified person or a records management company to step in for clients if the licensee dies or becomes incapacitated, and must keep the board informed of that name. A qualified person is an LCSW or other Oregon-licensed mental health professional, or a certified alcohol and drug counselor.

Psychologists: OAR 858-010-0060

The psychology board's OAR 858-010-0060, amended September 11, 2023, is the most itemized of the three. Seven years from last service, and the record must hold the client's name and identifying information; the presenting problem, purpose or diagnosis; the fee arrangement; the date and substance of each billed or service-count contact; test results and the basic data behind them; notes and results of formal consultations; copies of evaluative reports; releases; and signed informed consents. Psychologists too must name a qualified person, defined as an active or semi-active Oregon licensed psychologist, and the rule says failing to comply is unprofessional conduct.

The common thread is seven years from the last service, whichever board licenses you. The HIPAA and record retention lesson covers how that sits alongside the federal clocks.

The treatment plan

Every board above expects something that functions as a plan. OBLPCT calls it counseling goals or objectives, the social work board calls it a treatment or intervention plan, and the APA guideline calls it a plan for services, "updated as appropriate". None of them prescribes headings. The structure most clinicians use, and the one the treatment plan template attached to this lesson follows, is a presenting problem and diagnosis, goals in the client's language, measurable objectives under each goal, the interventions you will use, a target date, and a review date. That is common practice, not a rule. If a payer or an agency has its own required plan format, theirs governs.

The Professional Disclosure Statement

For OBLPCT licensees and temporary practitioners, the PDS is its own document, and OAR 833-075-0050 lists what must be in it: your name, business address and phone; your philosophy and approach; a statement of adherence to the Board's Code of Ethics (which OAR 833-100-0011 adopts as the 2014 ACA Code of Ethics); a client bill of rights (minimum qualifications, the Board's public records, a copy of the Code, how to complain, cost before services, confidentiality with each exception explained, freedom from discrimination); your formal education, highest relevant degree and the school; Oregon's continuing education and supervision requirements; your fee schedule; the required sentence pointing to the Board's website; and the Board's name, address, phone and email. Registered associates have their own rule, OAR 833-050-0031, with the same list plus the supervisor's name and the supervision requirements, and the same distribution terms.

If you deliver the PDS electronically, you must have a way to document that the client received and acknowledged it. It must be accessible to people with disabilities. A licensee who fails to provide a PDS may not charge the client a fee for services. The rule itself says only "each client"; the Board's PDS page supplies the timing, stating that the PDS goes to every client "at the onset of counseling or therapy, prior to" the service.

The exemptions are narrower than they look. Inactive licensees and those not practicing in Oregon are exempt, as are crisis response, residential psychiatric work, and employment by a correctional institution. Employment by a government agency, a public university, an OHA-licensed or certified organization, or a group practice is exempt only if the employer supplies a PDS, informed consent, or an equivalent document with everything section (1) requires. A county-agency LPC whose employer hands out nothing equivalent is not exempt.

Board pre-approval ended June 7, 2024

Older guidance said to send the PDS to the Board for approval. OBLPCT's PDS page states that effective June 7, 2024 there is "no longer a requirement to submit any PDS" to the Board office for approval, and the rule's own history shows the amendment filed and effective that day. The Board can still ask to see one, and the content requirements did not change. In September 2026 at least one third-party rule mirror still showed the older language, so read the rule at the Secretary of State's site.

Three habits that follow from the rules

• Write the note the same day. "Concurrently" is the boards' word, and finishing the note before the next client satisfies it.
• Keep the plan moving. "Updated as appropriate" is APA's phrase; a plan that never changes reads as a form filled in once.
• Name your backup now. It is required for LCSWs and psychologists, and a plan for your own incapacity is easier to write while nothing is wrong.

This is how I read these rules as an Oregon LPC, with the primary sources listed below; it is not legal advice, and your board, your supervisor or an attorney has the final say on what your record needs.

Real example from my own filing

Two documents attached below come from my associate years, rebuilt and redacted: the Professional Disclosure Statement every client signed, with the supervisor's name and the fee removed, and the Board's supervision report as a blank grid. Notice that the disclosure statement is the Board's list of required elements with one paragraph that is yours to write, and that the fee line is the one that changes most. Notice that the supervision grid is filled monthly, because a month short of the minimum supervision hours drops that month's client hours.

Further reading

• ICANotes: Types of therapy notes. A side-by-side of SOAP, DAP, BIRP and several other formats from a company that builds documentation software.
• ICANotes video: Tips for writing better mental health SOAP notes. Section-by-section advice on writing each of the four parts.
• Mentalyc podcast: How to choose a progress note format. A discussion of when SOAP, DAP or BIRP fits a practice, from a clinical-documentation software maker.