Clinical Notes by Profession
Each profession documents differently. BCBAs write session data and RBT supervision notes, social workers record resources and coordination, SLPs and OTs track measurable function, and therapists tie every progress note to a treatment plan. Pick your role to see the formats it uses, the documentation rules to know, a fictional example note and free tools.
What each profession page covers
Every page is written for one role and follows the same structure, so you can compare them side by side:
- Note formats: the formats that role uses most and when each one fits, with a link to the full template.
- Documentation requirements: what payers, boards and certifying bodies commonly expect in that role's notes, written as a starting checklist because rules vary by payer and state.
- A fictional example note: a de-identified sample that uses initials, never names, to show the level of detail.
- CPT codes and free tools: the codes that role commonly bills and the generators and calculators that match its work.
How documentation differs by role
- Therapists and counselors: write progress notes in SOAP, DAP or BIRP format that tie each session to a treatment plan goal.
- BCBAs: write session notes, treatment plan updates and supervision notes for each RBT they oversee.
- RBTs: document the targets run, prompt levels, data collected and notable behavior for each direct session.
- Social workers and case managers: record resources, referrals and care coordination alongside clinical observations.
- SLPs and OTs: track measurable functional goals and progress toward them.
Supervising associates, interns or RBTs? The clinical supervision notes template covers hours, cases reviewed, supervisee development and follow-up.
Not sure which format to use?
- Browse all 15 note templates: each with filled examples and a section-by-section guide.
- Take the note format quiz: four questions about your setting and sessions, then a recommendation.
- Clinical supervision notes template: for licensed supervisors and BCBAs documenting supervision.
Questions about documentation by profession
Which note format do most clinicians use?
SOAP is the most widely used progress note format across healthcare. In counseling and behavioral health, DAP and BIRP are also common, and goal-first formats such as GIRP suit ABA and rehabilitation work. If your employer, payer or board requires a format, use that one.
Can I use the same note format if I work in more than one role?
Yes, as long as each note meets the requirements of the service it documents. Many clinicians keep one format for therapy sessions and a different one for supervision or case management, because those notes answer different questions.
Are the example notes on these pages real?
No. Every example is fictional and de-identified. Examples use initials or "Client" instead of names and show structure and level of detail, not clinical advice for a real person.
Do these pages replace my board's or payer's rules?
No. The requirements on each page are a starting checklist. Your licensing board, certifying body, employer and each payer set the rules that apply to you, and those rules change, so check the current versions before you rely on them.