Clinical documentation can be challenging especially when we’re balancing our therapeutic presence with the need for clarity, compliance, and professional precision. The SIRP note (Situation, Intervention, Response, Progress) offers a simple yet effective framework used across different kinds of therapy, case management, and social services. It ensures that each note captures not just what happened, but also how the client is moving toward their goals.
Below I’ll walk you through a section-by-section guide, reflective cue questions, practical writing tips, and a full example note to illustrate how it all comes together.
S: Situation
The Situation section describes the client’s current presentation and the reason for the session. It establishes medical necessity and sets the clinical context for your interventions.
Tips for writing the Situation section:
- Focus on observable data and client self-report rather than interpretation.
- Note the triggering event or concern that prompted the session.
- Include relevant symptoms, emotions, or functional difficulties (e.g., difficulty sleeping, panic, work stress).
- Identify safety issues, environmental changes, or risk factors.
- Write in concise, professional language that supports medical necessity (for example: “Client continues to experience moderate anxiety symptoms impacting concentration at work.”).
👩🏻💻 Clinician reflection questions:
- What brings the client to today’s session?
- How is the client presenting emotionally, cognitively, and physically?
- What contextual stressors or events are influencing their current state?
- What evidence supports the ongoing need for treatment?
I: Intervention
The Intervention section outlines what you did during the session – your therapeutic actions, techniques, and reasoning. This part demonstrates your clinical skill and supports insurance or audit requirements.
Tips for writing the Intervention section:
- Use specific, active verbs: “explored,” “guided,” “taught,” “modeled,” “reinforced.”
- Mention the therapeutic approach used (CBT, EMDR, DBT, motivational interviewing, etc.).
- Document any resources, homework, or handouts provided.
- If relevant, describe coordination of care or communication with other providers.
- Avoid generic statements like “provided support” — instead, specify how support was offered.
👩🏻💻 Clinician reflection questions:
- What interventions did I use and why?
- How did I tailor these to the client’s unique needs?
- What theory or clinical rationale guided my actions?
R: Response
The Response section captures the client’s in-session reactions – cognitive, emotional, and behavioral. It reflects how the client engaged with interventions and whether they seemed to benefit.
Tips for writing the Response section:
- Include verbal statements that show insight, understanding, or resistance.
- Note observable affect and body language (e.g., tearful, tense, calm, smiling).
- Highlight any shifts in perspective or emotional tone.
- Keep it objective — describe the client’s reactions without judgment.
👩🏻💻 Clinician reflection questions:
- How did the client respond to interventions?
- What new insights or feelings were expressed?
- Did the client demonstrate motivation, avoidance, or openness to change?
- Did their symptoms, demeanor, or engagement change during the session?
P: Progress
The Progress section summarizes clinical outcomes and outlines the plan moving forward. It provides continuity across sessions and shows accountability to the treatment plan.
Tips for writing the Progress section:
- Describe improvements, regressions, or plateaus since last session.
- Link observations back to treatment goals.
- Note any new short-term objectives or homework.
- Address risk assessment or safety planning when relevant.
- End with a clear plan for next steps: frequency, focus, and anticipated interventions.
👩🏻💻 Clinician reflection questions:
- How is the client progressing toward treatment goals?
- What changes warrant continuation or modification of the treatment plan?
- What specific focus or method will guide the next session?
Example SIRP Note
Client: Darlene Alderson (pseudonym)
Date of Session: October 23, 2025
Duration: 45 min.
Start time: 9:00 am
End time: 9:45 am
Diagnosis: F41.0: Panic disorder without agoraphobia
CTP Code: 90834 (Psychotherapy 45 min)
Situation:
Client reported elevated anxiety and disrupted sleep due to upcoming performance evaluations at work. She described difficulty concentrating and irritability toward her partner. She however reports no panic attacks this week. Affect was tense but cooperative. No suicidal ideation or acute risk reported.
Intervention:
Reviewed recent coping attempts and introduced progressive muscle relaxation and 4-7-8 breathing. Provided psychoeducation on the physiological stress response and how relaxation reduces somatic arousal. Guided client through a brief practice and assigned nightly use with a one-week sleep log.
Response:
Client participated willingly, initially laughing nervously but later reported, “I actually feel calmer now.” She expressed motivation to try the exercise at home and asked thoughtful questions about implementation.
Progress:
Compared to last session, client appeared more hopeful and engaged in self-care. Anxiety symptoms persist but are less overwhelming. Panic attacks have significantly reduced in frequency. Plan to review the sleep log next session, reinforce daily relaxation practice, and explore cognitive restructuring techniques if anticipatory worry continues.
Clinician (signed):
Krista Gordon, Ph.D.
Electronic signature: Oct 23, 2025, 4:00 PM
Writing SIRP notes that demonstrate Medical Necessity:
Always ensure your note connects symptoms, interventions, and progress toward measurable goals. A well-written SIRP note demonstrates that your services are medically necessary and goal-oriented – essential for clinical integrity, continuity of care, and audit readiness.
How Note Designer Can Help:
Writing high-quality notes doesn’t have to be time-consuming. Note Designer offers ready-to-use SIRP note templates designed for therapists, counselors, and social workers. Each section includes professionally written prompts and drop-down content to guide your writing. Once you’ve selected and personalized your content, you can use our optional AI feature to polish and finalize your note. Whether you choose to use our Ethical AI feature or not, Note Designer helps you ensure that your documentation remains clear, professional, and compliant.
Note Designer: Helping to keep your clinical documentation fast, consistent, and clinically sound for over 10 years!
Patricia C. Baldwin, Ph.D.
Clinical Psychologist
President of
Note Designer Inc.
👩🏻💻 Author of Note Designer: A simple step-by-step guide to writing your psychotherapy progress notes (2nd Edition- updated and expanded); 2023
For more guidance on how to write different types of progress notes and reports, check out my other blogs listed here: