Permissions: All Access Levels can submit notes.
Below are the steps to creating a BIRP Note for an individual Client. Your Notes will automatically save as you work.
Related Articles: Review, Lock, Sign, & Modify Notes Workflow; Effective Documentation Training Webinar; Write a Group Note: PIE, BIRP, & Universal Group Notes
Jump to Section: [Create BIRP Note] [Required Note Information] [Sign and Submit Note]
Create BIRP Note
- Hover over the Note Center tab in the navigation bar and locate the BIRP Notes, then select Create New Note from the drop-down.
Enter Required Note Information
Note: Required fields are bolded in blue.
- Enter Date of Service.
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Select Client(s) name.
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- If needed, review Client Requirements Outstanding, Service Authorizations, Most Recently Created Note, DSM-5 Diagnosis Listing and Diagnosis Listing for Client.
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- Select Service Code, as well as Start and End Time.
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- Select Service Location, Service Delivered and Setting.
Note: If allowed by your Location Administrator, you can select a different location that you would like to bill from the Service Location drop-down.
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- Select Person(s) Involved, and Contact Type.
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- Choose Consumer's Overall Affect (only one).
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- Enter Relevant Changes in medical condition and/or medications (health and safety stressor) since last visit.
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- Select Client Progress.
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- Expand to Add New Goals for clients to add additional Goals, Objectives or Interventions.
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- Select Service Plan Objectives/Interventions and click Add to List.
Important: You must select at least one Goal, Objective, and Intervention for your Note.
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- Enter Mandatory Note fields for Behavior, Intervention, Response, and Plan. Use the Word Bank on the left for adjectives and verbs to help build your entry.
Note: A Minimum Number of Characters may be required depending on Preferences set by your Administrator.
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Sign and Submit Notes
- Check the I Agree to the terms of the Attestation Statement box.
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- Enter your PIN to add your electronic signature.
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- Click Submit. A green Note Submitted Successfully bar will display to confirm that your note was submitted.
IMPORTANT: If you do not see the green confirmation, scroll through the note to find required fields, errors, or other fields that were missed or entered incorrectly.
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