BIRP: Create BIRP Note

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

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Create BIRP Note

1. 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

Enter Date of Service.
Select Client(s) name.
If needed, review Client Requirements Outstanding, Service Authorizations, Most Recently Created Note, DSM-5 Diagnosis Listing and Diagnosis Listing for Client.
Select Service Code, as well as Start and End Time.
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.
Select Person(s) Involved, and Contact Type.
Choose Consumer's Overall Affect (only one).
Enter Relevant Changes in medical condition and/or medications (health and safety stressor) since last visit.
Select Client Progress.
Expand to Add New Goals for clients to add additional Goals, Objectives or Interventions.
Select Service Plan Objectives/Interventions and click Add to List. Important: You must select at least one Goal, Objective, and Intervention for your Note.
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.

Sign and Submit Notes

Check the I Agree to the terms of the Attestation Statement box.
Enter your PIN to add your electronic signature.
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.