Upheal has many different AI-powered note types available to save healing professionals time and energy on administrative work. We offer both psychotherapy and psychiatric note types, as well as notes for both individuals and couples.

In case you’re not already familiar with these note styles, our team of mental health professionals has provided a brief explanation of each type and its benefits.

Therapy notes are designed to track session details and therapy-specific progress, including behavioral insights, therapeutic interventions, and plans.

Available for individuals & couples

Our own default progress notes include the Client Presentation, Therapeutic Interventions, Assessment, and Plan sections. Our AI has been trained on mental health data to capture the most important progress note information for you.

Available for individuals & couples

SOAP stands for Subjective, Objective, Assessment, and Plan. This note type is oriented towards effectively tracking the client’s progress, thoughts, behavioral changes, and subjective experiences, as well as facilitating therapeutic insights and enabling effective planning for the next session.

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SOAP notes are suited to medicine in general because the subjective and objective sections are separate. However, in mental health sessions, most likely only the physical presentation and assessment results can be recorded.

Available for individuals & couples

DAP stands for Data, Assessment, and Plan. It combines subjective and objective data in one section and primarily focuses on the client’s goals and the interventions used to address those goals.

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Many mental health professionals prefer the DAP note because it doesn't require the categorization of information as objective or subjective and they can simply include everything as data.

GIRP stands for Goals, Intervention, Response, and Plan. It helps therapists focus on the specific goals and objectives identified by the client for their therapy. The GIRP format outlines the therapeutic interventions and techniques used, evaluates their effectiveness, and facilitates planning for continued progress and growth.

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GIRP-formatted notes are perfect for when a client and mental health professional have defined a clear goal together. It helps show the client their ability to make small steps toward larger objectives, offering encouragement.

BIRP stands for Behavior, Intervention, Response, and Plan. BIRP notes include the subjective and objective data from your session in one place, the Behavior section. By outlining the therapist's interventions based on client behavior and capturing the client's subsequent responses, this format highlights the role of the therapy in the client’s progress.

BIRP notes are especially useful in the behavioral health field. This format focuses on the effectiveness of therapy and is also helpful for studying therapist behavior.

EMDR stands for Eye Movement Desensitization and Reprocessing, which is a therapy technique. This approach is primarily used to treat PTSD and traumatic events. EMDR notes may include details about the client’s emotional and physical responses, shifts in beliefs or perceptions, and any insights gained during the session.

EMDR notes allow for very detailed tracking of traumatic memories, associated cognition and emotions, and a scale for the validity of the image/incident itself. Accompanying emotions are rated and located in the body, followed by bilateral stimulation and desensitization.

The MSE is a standard tool used by clinicians to assess the basic functioning of a client. The assessment categories include mood, cognition, perception, thoughts, behaviors, insight, and judgment.

The enhanced SOAP format uses a more nuanced structure that extends beyond the basic SOAP format, encompassing diverse clinical domains and more detailed rationale for care. It emphasizes individualized factors and clarifies targeted objectives. Compared to standard SOAP notes, this approach supports richer understanding and more responsive, tailored interventions.

This SOAP template aligns with Headway's note structure, capturing clinical summaries, diagnostic support statements, medical necessity, and progress toward treatment objectives.

Use Intake notes during an intake session to automatically capture answers to standard questions such as personal and social history, family background, and any previous treatment received.

This comprehensive assessment captures the client’s main concerns, symptoms, and reasons for seeking treatment alongside psychological, biological, and social factors that influence a client’s wellbeing. This assessment provides a holistic view to help inform diagnosis and guide individualized treatment planning.

Psychiatric notes are designed to track psychiatry-specific insights, including information about medications and diagnoses.

Includes important MSE criteria under the Objective section to capture Appearance, Emotions, Thoughts, Cognition, Judgment, and Insight. This format identifies and spell checks medication names, captures dosages, changes, and side-effects, and also contains a lab results and risk assessment section.

Use psychiatric intake notes during an initial patient evaluation for a complete psychiatric assessment. These notes capture chief complaints, mental status, family/social backgrounds, medical and substance histories, and DSM diagnoses leading to an informed treatment plan.

Our Medical SOAP notes include the Subjective (patient-reported symptoms and histories), Objective (observations, measurements and test results discussed), Assessment (diagnosis and evaluation), and Plan (treatment and follow-up) sections.
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