Substance Abuse Progress Note Examples, Intake to Discharge
Substance abuse progress note examples in SOAP, DAP, and BIRP, with intake, treatment plan, and discharge excerpts, and where a note ends and disclosure begins.
A substance abuse progress note has one job: a reader who opens it cold should understand the service, the intervention, the client's response, and the next step without opening another document. The note also has to connect to the documents on either side of it, the intake assessment and treatment plan that gave it a reason, and the discharge summary that will close the episode. Ease is the platform where the full SUD documentation set, intake assessment through discharge summary, is created in one system that also holds the release-of-information authorizations around it.
The examples below show how those four documents connect. They are illustrative notes, not patient records, measured outcomes, or universal templates. Adapt them to the encounter, your organization's requirements, and the payer and jurisdiction you bill under.
What a substance abuse progress note has to do
A standalone progress note identifies the encounter, ties the service to an assessed need, records what the clinician did, and documents how the client responded.
Los Angeles County's Substance Abuse Prevention and Control division publishes a set of SUD documentation examples for its network providers, covering the service request, progress notes, the treatment plan, and the discharge or transfer form. Its progress-note section makes the case plainly: notes chart a client's recovery and progress through the levels of care of their treatment, and note writing is the clinician's chance to reflect on the session rather than react to the latest crisis. It is one county's manual, written against that county's contract requirements, so read it as a worked example rather than a national rule.
Include, as applicable:
- Service date, setting, participants, start and end times, and the clinician's identity and credential
- The assessed problem or treatment plan objective the session addressed
- The client's report and the clinician's observations, kept distinct
- The intervention delivered and the client's response to it
- Current safety concerns and any action taken
- Progress or barriers, followed by a specific next step
The central link is the chain from assessed problem to plan objective to session intervention to client response. Naming the objective helps a reviewer follow the chain, but "Goal A addressed" cannot replace a description of the encounter itself. Our progress note phrases resource collects wording for each of the six items above.
Intake assessment example: the clinical starting point
An SUD intake assessment records what is needed to understand the presenting concern, the immediate safety needs, and the initial treatment direction.
| Intake element | Document |
|---|---|
| Presenting concern | The client's stated reason for seeking services, in their words where possible |
| Substance use | Substances, pattern of use, last use, withdrawal history, overdose history, prior treatment |
| Health and context | Relevant medical and psychiatric history, medications, housing, relationships, supports |
| Safety | Current risk findings and any action taken |
| Clinical impression | Diagnosis or provisional impression and the reasoning behind it |
| Initial plan | Recommended services, further assessment, referrals, follow-up |
Illustrative intake excerpt, not a patient record.
Presenting concern. Client requested help with alcohol use after missed work and conflict at home. Client stated, "I want to stop drinking, but I'm worried about what happens when I try."
Substance use and safety. Client described daily alcohol use and reported shaking after previous attempts to stop. Clinician assessed current symptoms and immediate safety and identified the need for medical evaluation of possible withdrawal. Other substance use and health history remain to be assessed.
Initial plan. Arrange medical evaluation for withdrawal concerns, complete the remaining biopsychosocial assessment, and review treatment options with the client after the evaluation.
Where a program uses the ASAM criteria, the intake records the clinical factors behind the level-of-care recommendation; our ASAM levels of care guide covers those dimensions. An unfinished assessment names the outstanding items rather than implying it was completed. For the condition itself, see our substance use disorder glossary entry.
Treatment plan example: turning an assessed need into an objective
An SUD treatment plan turns an assessed problem into an observable objective, a named intervention, and a way to review progress.
The county manual above describes the plan as the place where short- and long-term treatment goals are consolidated along with a plan for how those goals will be achieved, both within a level of care and in collaboration with outside partners. A SMART objective is specific, measurable, achievable, relevant, and time-bound. Review intervals and required plan contents depend on the program, payer, and jurisdiction, so no single update deadline belongs in a template.
| Assessed problem | Illustrative objective | Planned intervention | How progress is reviewed |
|---|---|---|---|
| Alcohol use tied to social pressure and missed work | Client will identify high-risk situations and practice a refusal response before the next plan review | Individual cognitive behavioral therapy and between-session skills practice | Client report, demonstrated skills, attendance, and reported use |
| Opioid cravings during the commute | Client will develop and use a safer commute and a craving-response plan | Motivational interviewing, relapse-prevention work, coordination with the prescriber | Client report of cravings, plan use, medication follow-up |
| Anxiety associated with substance use | Client will practice non-substance coping strategies when anxiety rises | Skills-based therapy and coordination with psychiatric care where indicated | Skills practice and the client's account of use in daily life |
The plan also names the responsible clinicians, service frequency, target dates, and the client's participation where those apply. Our treatment planning best practices guide and treatment plan template cover the structure; any template still has to reflect the individual assessment.
Substance abuse progress note examples: SOAP, DAP, and BIRP
SOAP, DAP, and BIRP organize the same task differently: record the service, the intervention, the client's response, and the next step.
The three examples below are fictional and deliberately avoid invented scores, test results, or outcomes presented as evidence.
SOAP example: individual alcohol-use counseling
SOAP separates the client's report, the clinician's observations, the assessment, and the plan.
Encounter. Individual SUD counseling; setting and time recorded in the encounter fields.
S, Subjective. Client reported an invitation to meet friends at a bar and declining it. Client said the invitation led to difficulty sleeping and worry about drinking, and asked for help preparing for future invitations.
O, Objective. Clinician used cognitive behavioral therapy to map the invitation, the associated thoughts, the urge, the refusal response, and the sleep concern. Client participated in a refusal-skills rehearsal and named a supportive person to contact. Clinician assessed current safety and recorded the findings.
A, Assessment. Session addressed the treatment plan objective of responding to social drinking triggers without alcohol use. Client demonstrated a refusal response in rehearsal and identified insomnia as a continuing barrier.
P, Plan. Client will practice the refusal response and record situations that disrupt sleep. Next session reviews the record and builds a sleep-related coping plan. Clinician will follow up on any safety or withdrawal concern identified.
Our SOAP notes guide covers the format in full.
DAP example: group relapse prevention
DAP combines reported and observed information under Data, then records the assessment and plan.
Encounter. Group relapse-prevention service; attendance, setting, and time recorded in the encounter fields.
D, Data. Client described feeling lonely before passing a former using environment. Clinician led an exercise tracing the sequence from loneliness to craving and rehearsed a coping response. Client described using an urge-management skill outside treatment and took part in group discussion. Clinician recorded the client's current safety status.
A, Assessment. Session addressed the objective of recognizing triggers and using relapse-prevention skills. Client identified a trigger sequence and described applying a previously practiced skill. Loneliness remains a treatment focus.
P, Plan. Continue relapse-prevention work. In the next individual encounter, develop a plan for responding to loneliness and identify support contacts the client agrees to use.
A group note is one note per participant. The group's shared content is the same across the set; each client's data, assessment, and plan are their own.
BIRP example: opioid cravings and medication follow-up
BIRP leads with observable behavior, then the intervention, the response, and the plan.
Encounter. Individual SUD counseling; setting and time recorded in the encounter fields.
B, Behavior. Client reported cravings when driving past a former drug-use location and reported taking prescribed medication as directed. Clinician recorded relevant observations and current safety findings.
I, Intervention. Clinician used motivational interviewing to explore an alternate commute and cognitive restructuring to examine the thought that using "just once" would be harmless. Clinician and client reviewed the existing relapse-prevention plan.
R, Response. Client identified an alternate route, practiced a coping statement, and named a barrier to using the new route on workdays.
P, Plan. Client will test the route when feasible and track cravings for the next session. Clinician will coordinate medication-related concerns with the prescriber under the client's authorizations and the applicable disclosure rules.
Which format to use depends on the organization's workflow and its payers, not on a claim that one format proves better outcomes. Our progress note glossary entry defines the terms.
Discharge summary example: recording the transition
An SUD discharge summary states why treatment began, what services occurred, the client's status at discharge, and what follow-up was arranged or offered.
The county manual frames discharge and transfer as movement through a continuum of care, from withdrawal management through outpatient, intensive outpatient, residential, inpatient, and opioid treatment programs. A useful discharge record separates completed care from planned care, names unresolved risks and the client's stated preferences, and does not claim a referral turned into an appointment unless that was confirmed.
Illustrative discharge excerpt, not a patient record.
Reason for admission. Client sought treatment for alcohol use affecting work and relationships.
Services provided. Individual counseling, relapse-prevention group services, and coordination with other treating professionals, as recorded in the service history.
Status at discharge. The client's reported use, observed functioning, remaining concerns, and current safety assessment, with each treatment objective marked addressed or still active.
Relapse-prevention plan. Client identified social invitations involving alcohol and disrupted sleep as triggers, practiced a refusal response, named a support contact, and agreed to raise continuing sleep concerns with a treating professional.
Continuing care. Referral names, verified contact details, and instructions for arranging follow-up, with referrals offered distinguished from appointments confirmed.
Client participation. The client's review of the plan, and their agreement, requested changes, or decision not to take part.
If a client leaves against clinical advice, document the stated reason, the assessment possible at departure, the recommendations and referrals offered, and the client's response. Never record a declined service as completed.
Progress notes are not psychotherapy notes
A routine progress note is part of the clinical record, and labeling it "process notes" does not change what it contains.
The HIPAA definition of psychotherapy notes at 45 CFR 164.501 sets those notes apart from the rest of the record and excludes from them medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment, results of clinical tests, and any summary of diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. Everything in the SOAP, DAP, and BIRP examples above falls on the record side of that line.
Documentation is one question, disclosure is another
A clinically complete note does not authorize anyone to share it, and a signed authorization does not make an incomplete note complete.
42 CFR 2.12 sets out when the Part 2 restrictions apply: records that would identify a patient as having or having had a substance use disorder and that contain information obtained by a federally assisted program. Where they apply and a disclosure rests on consent, 42 CFR 2.31 lists what the written consent has to contain, including the information to be disclosed, the recipient, the purpose, and when the consent expires. The BIRP plan above, coordinating with a prescriber under the client's authorizations, is that line drawn in a note. Our 42 CFR Part 2 guide covers the rule in depth.
A clinical director reviewing an episode can follow the record from intake through plan, notes, plan updates, and discharge. The review tests whether the documents agree with each other, not whether a note mentions a plan objective.
| Review question | What the record should show |
|---|---|
| Why was the service provided? | An assessed need connected to this encounter |
| What happened in treatment? | The intervention and the client's response |
| What changed? | Documented progress, continuing barriers, or a revised clinical direction |
| What happened at transition? | Status, unresolved needs, and follow-up offered or arranged |
| Was information disclosed appropriately? | The legal basis and the authorization or other documentation behind it |
Timeliness, plan-review intervals, and discharge deadlines come from the governing requirements for the particular service and payer, not from a sample note. Our substance abuse billing guide covers the reimbursement side of the same episode.
How Ease Health handles SUD documentation
Ease was built from the ground up as one behavioral health platform, with CRM, EHR, and RCM in a single product with one login and one patient record. The four documents in this guide live in that one chart.
- One chart across levels of care. A client who moves from detox to residential to IOP to outpatient stays in one chart, so the intake, plan, notes, and discharge summary of each stage sit together.
- Your own note types. An organization defines its own note types and appointment types, so intake, progress, and discharge notes are types you configure, stored and audited in the same chart.
- Treatment plan in the chart. Treatment planning lives inside the record, so a progress note's objective is the plan's objective, not a retyped copy.
- Release-of-information authorizations as records. Ease keeps a release-of-information authorization as a signed form with an expiration date. A withdrawn authorization is stamped revoked rather than deleted, and the release-of-information tab is set up per organization.
- AI narrative drafting, clinician sign-off. Where AI documentation is enabled for your organization, AI narrative generation proposes a narrative from what is already documented; the clinician edits, selects, and signs it.
What Ease does not do: it does not decide what your notes contain, its consent objects are separate features rather than one uniform module, some of them are enabled per organization by Ease, and none of them is a compliance guarantee. Whether a disclosure is lawful is your program's determination, made against the rule and the authorization in front of you.
Questions to bring to a demo
- Show me an intake, a progress note, and a discharge summary for one client. Which fields carried forward, and which were typed?
- How do I set up our own progress note type with the six items above as required fields?
- Where does the treatment plan objective appear when a clinician writes a note against it?
- Show me a release-of-information authorization, its expiration, and what happens when it is revoked.
- Show me a group session documented as one note per participant.
Frequently Asked Questions
What should a substance abuse progress note include?
The encounter details, the assessed need or treatment plan objective addressed, the intervention delivered, the client's response, any safety finding and the action taken, an assessment of progress or barriers, and the next step. Record only what the encounter supports.
Does a progress note have to quote the treatment plan?
No. It has to make the link to the assessed need or plan objective clear. A copied goal is not a substitute for documenting the service and the response, and a note that reads 'Goal A addressed' without describing the encounter does not stand on its own.
Which format should a clinician use: SOAP, DAP, or BIRP?
The one your organization and payer accept. SOAP separates the client's report from the clinician's observation, DAP combines them under Data, and BIRP leads with behavior and intervention. All three still need a complete, encounter-specific account.
Is a progress note the same as a psychotherapy note under HIPAA?
No. The HIPAA definition at 45 CFR 164.501 sets psychotherapy notes apart from the rest of the record and excludes from them medication monitoring, session start and stop times, modalities and frequencies, clinical test results, and any summary of diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress. A routine progress note is the record, not a psychotherapy note.
Does a signed SUD progress note allow disclosure to another provider?
No. Writing and signing the note is one question and having a lawful basis to disclose it is another. Where 42 CFR Part 2 applies, a written consent under 42 CFR 2.31 has to name the information to be disclosed, the recipient, the purpose, and when it expires.
