PIRP NOTE

Client: [Name or ID, date of birth]
Session date: [Date]
Time: [Start, end, and total minutes]
Session type: [Individual, couple, family, or group; session number in this episode of care, such as 4 of 6]
Format and place: [In person at the office, or video or phone with the client's location]
Participants: [Everyone who took part, by role, or client only]
Clinician: [Name, credentials]
Diagnosis on the plan: [Working diagnosis, and the date the plan was agreed]

PROBLEM
Plan problem addressed: [Problem number and its wording on the treatment plan]
Linked objective: [The objective for this problem, its measure, target, and target date]
How it shows now: [Current symptoms or behaviors: how often, how strong, and what has changed since last session]
Plan measure: [Today's rating, log total, or score, beside the baseline]
Client's account: [In the client's words, what has been hardest with this problem lately]
Why care is still needed: [What the problem is doing to work, sleep, home, health, or safety]
Other problems raised: [Anything new, and whether it belongs on the plan, or none]

INTERVENTION
Approach: [The model in use: CBT, motivational interviewing, behavioral couples therapy, solution-focused, problem-solving, or other]
What was done: [Each technique by name, and what it involved today]
Aimed at: [The problem and objective each technique targets]
Homework set: [Tasks agreed, and how the client will track them]
Coordination: [Contacts with prescribers, family, or other services, and the consent for each]

RESPONSE
In session: [Engagement, understanding, and any skill shown or practiced]
Presentation: [Mood in the client's words, affect, behavior, thought process]
Result: [The plan measure now, beside the baseline and the target]
Problem status: [Resolved, improving, unchanged, or worse, and the evidence]
Safety: [What you asked about suicide, self-harm, harm to others, and substance use; the answers; your judgment]
Barriers: [What got in the way of homework or change]

PLAN
Before next session: [What the client will do, and how they will record it]
Clinician actions: [Calls, letters, or referrals, each with a date]
Next session focus: [The problem and technique to take up next]
Plan changes: [Changes to the problem list, objectives, frequency, or level of care, or none]
End point: [Sessions left, or the result that will close this problem]
Next appointment: [Date, time, and format]

Clinician signature: [Name, credentials, date and time]