Progress notes that pass audits: SOAP charting, DAP and BIRP notes

What is a progress note, and what are the types of progress notes?

A progress note records one visit or session: what was done, for how long, why it was needed and who signed it. Florida Medicaid’s recordkeeping rule lists 11 items to document for each visit (several only as applicable), and its therapy coverage policy (§6.2) requires “Daily progress notes that address each service provided.” Medicare’s Program Integrity Manual (PIM) covers signatures, corrections and psychotherapy notes (ch. 3, §§3.3.2.4 to 3.3.2.6). None of the three names a layout, so the “types” are layouts you choose (SOAP, DAP, BIRP) and visits payers read differently: medical visits, psychotherapy sessions and treatment-plan reviews.

What is SOAP charting, and how do DAP and BIRP progress notes compare?

SOAP stands for subjective, objective, assessment, plan. It comes from the problem-oriented medical record, which a 2026 peer-reviewed analysis traces to the mid-1960s and says includes the SOAP note among its features. DAP (data, assessment, plan) and BIRP (behavior, intervention, response, plan) are two other layouts. We found no government or peer-reviewed definition of either, so treat all three as conventions. Use the table as a cheat sheet; the placement is convention, not rule.

Source: Rule 59G-1.054(2), F.A.C.; PIM ch. 3; MLN006764; First Coast; HHS-OIG A-09-21-03021; read Oct 20, 2026. Placement is convention.

How do you write progress notes that pass a Medicare or Medicaid review?

• Psychotherapy. Write the minutes, or the start and stop times, of the psychotherapy itself. Codes follow time: 90832 for 16 to 37 minutes, 90834 for 38 to 52, 90837 for 53 or more, and nothing under 16 (First Coast). With an E/M visit the same day, the two must be “significant and separately identifiable,” and the E/M’s history, exam and decision-making time does not count as psychotherapy. OIG disallowed a $99 psychotherapy payment where the record gave only a 60-minute total for the encounter.
• Medical visits. Since January 1, 2023, most E/M levels follow medical decision-making or time. History and exam must be medically appropriate, but their extent “isn’t an element in selection of the level.” If time supports the code, record “a start and stop time or the total time” (MLN006764).
• Necessity and interventions. Records must “establish the medical necessity for and the extent of services provided” (Rule 59G-1.054(2)(a)1.). OIG reports that First Coast’s local coverage determination (LCD) L33252 requires “a detailed summary of the session, including descriptive documentation of therapeutic interventions.”

OIG sampled 216 enrollee days of Medicare psychotherapy provided from March 2020 to February 2021. Providers failed Medicare’s requirements on 128, and OIG estimated that $580 million of the $1 billion paid was improper. The sample was nationwide, from the first pandemic year: not Florida’s error rate.

What goes in a mental health or behavioral health treatment plan?

For therapy and behavioral health practices, Florida Medicaid’s Behavioral Health Assessment Services Coverage Policy requires every treatment plan to include:

• the amount, frequency and duration of each service for the plan’s six months, never “as needed” or a date range;
• the dated signature of the recipient, or of the guardian if the recipient is under 18;
• diagnoses consistent with the assessments, and discharge criteria;
• individualized, strength-based goals, the list of services, and measurable objectives with a target completion date for each goal;
• the treating practitioner’s statement that the services are medically necessary, and the treatment team’s signatures.

“Treatment plans become effective on the date of the treating practitioner’s signature. Florida Medicaid reimburses for services provided within 45 days of the signature.” A review is due once per six months or after a significant change; when nothing significant has changed, an addendum signed by the practitioner and the recipient can add or modify services.

Medicare depends on the contractor. OIG found that only three of seven Medicare contractors had an LCD requiring a treatment plan. First Coast was among the other four, but all four expected one: three told OIG so and the fourth said on its website that psychotherapy documentation should include one. Where a plan is required, it states the type, amount, frequency and duration of the services, the diagnosis and the anticipated goals.

What do Florida’s nursing rules say about nursing progress notes?

The Board of Nursing’s rule on unprofessional conduct names no note layout, so nursing SOAP charting is optional there too. It lists “Inaccurate recording” and “Falsifying or altering of patient records or nursing progress records” (Rule 64B9-8.005(1), (6)). Who may assess or delegate is in our scope of practice guide.

How do therapy and mental health progress notes differ from psychotherapy notes?

HIPAA defines psychotherapy notes as a mental health professional’s notes “documenting or analyzing the contents of conversation during a private counseling session” (or a group, joint or family session) “that are separated from the rest of the individual’s medical record” (45 CFR 164.501). Progress notes stay in the rest of the record, and the definition leaves out medication prescription and monitoring, session start and stop times, the modalities and frequencies of treatment, clinical test results, and any summary of diagnosis, functional status, treatment plan, symptoms, prognosis and progress to date. Medicare’s manual adds that combining them in one document “does not transform the non-protected information into protected psychotherapy notes” (PIM §3.3.2.6). Separating them changes two things:

• Authorization. Any use or disclosure of psychotherapy notes needs the patient’s authorization, with exceptions that include the author’s own treatment use, the practice’s supervised training programs for mental health trainees and defending itself in a legal action the patient brings (45 CFR 164.508(a)(2)). Their authorization “may only be combined with another authorization for a use or disclosure of psychotherapy notes” (164.508(b)(3)(ii)).
• Medicare reviews. “Under no circumstances” may Medicare’s review contractors request them, and refusing is not an automatic denial. The provider must extract what shows the services were reasonable and necessary, or “the claim shall be denied” (PIM §3.3.2.6).

Can you add to a progress note after the visit?

Yes, under each rule set’s conditions.

“All services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered.”

• Medicare. The date and author of any amendment, correction or delayed entry “should be identifiable,” and the change “clearly and permanently denoted.” Potentially fraudulent entries are referred for fraud review (PIM §3.3.2.5).
• Florida physicians. Entries must be “accurately dated and timed.” Late entries are permitted but “must be clearly and accurately noted as late entries and dated and timed accurately when they are entered into the record.” Office records need only be dated (Rule 64B8-9.003(5)).
• Florida Medicaid. AHCA’s overpayment findings rest “solely upon contemporaneous records,” and a provider may not present records to contest an overpayment unless they are contemporaneous and, if requested during the audit, were furnished. The statute does not preclude considering an addendum made before notice of the audit and germane to a note made at the time of care (s. 409.913(21)–(22), F.S.).

What you can do today

1. Audit five notes per clinician from last month against the 11 items in Rule 59G-1.054(2)(b) and, for psychotherapy, the minutes. Train staff on what you find (compliance training).
2. Check every active treatment plan against the list above, including a review in the last six months.
3. Separate the notes. Keep analysis of session conversation in its own file, and check every authorization form against 164.508(b)(3)(ii) above.
4. Label late entries. Set your EHR to stamp “late entry,” the date and time entered and the author (PIM §3.3.2.5; Rule 64B8-9.003(5)).
5. Start a signature log for anyone who signs with initials or an illegible signature: printed name, credentials and the initials used (PIM §3.3.2.4 C).

Advixor’s clinical documentation and quality assurance program includes weekly review of progress notes and monitoring of applicable documentation deadlines.