#birp notes

Record a service for every billing activity 

Provide a clear, ongoing record of the client’s condition, the interventions attempted, theclient’s response to the care provided, and the progress the client is making toward realizing his/her goals and objectives 

Facilitate the coordination of care and communication between team members 

Show evidence of collaboration with community resources including primary care 

Be legible and signed/dated appropriately by clinical staff

Include the license, title, or degree of service provider 

Demonstrate ongoing medical necessity for each billable service 

Show that the amount of time billed is appropriate for the service provided 

Show that content within the note corresponds with the respective billing activity that is being claimed. 

Be unique and non-repetitive in each section (i.e. Behavior, Intervention, Response, and Plan) from the note before it 

Accurately document the use of a specific therapeutic modality whenever such interventions are utilized (e.g. Cognitive Behavioral Therapy, Depression Treatment Quality Improvement, Moral Reconation, Dialectical Behavioral Therapy, Solution Focused Therapy, etc.)