Main image courtesy of Money and Mental Health. 

Accurate and consistent documentation is an important aspect of patient care, no matter what field you’re in. Whether you’re a physician or a mental health professional, chances are you’ve encountered (or have taken down) BIRP notes before. These notes focus on the behavior, intervention, response, and plan aspect of treating patients. BIRP notes allow clinicians to properly document what’s going on during a patient visit, but they tend to take up a lot of time and energy.

If they’re not written down immediately after the appointment, you can risk missing important information, and if you type them up while you’re conversing with the patient, you can risk not being entirely present for their concerns. Perhaps there’s a better solution to this with the introduction of AI for BIRP notes.

Want to know more about how this can benefit your practice? Keep reading because today we’re discussing:

• Why BIRP notes are a crucial part of healthcare
• The benefits of using AI for BIRP notes
• Some AI systems you should check out to help with BIRP notes

Why BIRP notes are an essential part of healthcare

BIRP notes give providers a clear picture of what’s going on with a patient at any given time

While they may seem tedious at times, creating accurate BIRP notes are an essential part of your job as a provider caring for patients. These types of notes ensure that important information transcribed at each session, allowing them to give a more complete picture of what treatments and plans have been working. Using these notes builds the doctor/patient relationship, and ensures that each patient’s unique scenario is right at the provider’s finger tips. There are many benefits to this documentation practice, including:

• Consistent way to gather patient information. No matter what type of healthcare facility you’re in, BIRP notes are an accurate way to gather pertinent information about patients. This is true for mental and behavioral health clinicians as well as other providers. Having a clear summary of exactly what’s going on provides doctors with the chance to get up to speed on past encounters. Providers are seeing multiple patients each day, and no one can remember everything about all their patients. But reviewing patient information in BIRP notes provides them with the chance to keep patient situations clear and organized.

• Accurate way to plan appropriate treatment. In addition to providing a space to put down information like the patient’s behavior, observable actions, their mood, and how they’re generally feeling, BIRP notes can also be a great way to identify patterns or areas in the patient’s circumstances that may require further investigation. Every patient’s situation is different, and having a variety of BIRP notes to examine from previous sessions is a fantastic way to create customized treatment plans that will benefit that particular patient.

• Effective way to evaluate what’s working (and what isn’t). The only way to determine what is and isn’t working is to know what has been tried in the past. Seeing what treatments have already been attempted and gauging the response from the patient is a helpful way to determine the effectiveness of what was prescribed. A review of previous BIRP notes will give the clinician a clearer picture and they can easily determine if anything needs to be adjusted or halted completely. 

• Can measure progress. How else can you measure the progress of the patient than by seeing how far they’ve come and the results of the treatment plans? BIRP notes offer better insight into tracking how the patient has improved, and if the goals of the treatment plan are being met. If there are areas for improvement, treatment can be adjusted based on whether or not the client has shown progress.

• Well-documented records can easily be shared. It’s important to note that having appropriate documentation can also improve how patient data is shared between providers or insurance companies. Sometimes there is more than one clinician caring for a patient, so transcribing good BIRP notes is essential to ensure everyone is on the same page. This is also true for any insurance companies that are paying for a treatment or service who want to know more details about the specific circumstances. 

What’s the difference between SOAP notes and BIRP notes?

Both SOAP notes and BIRP notes are used in a variety of healthcare settings in order to provide a clear overview of what’s going on with the patient, and to determine the effectiveness of their treatment plan. The difference between the two largely lies in the different sections of the notes and where the focus of the notes are. BIRP notes tend to be more focused on ensuring that there is documentation of the different types of interventions that have been used in order to meet the patient’s goals. 

Both types of notes aim to gather important information about the patient at the time of visit, and how to best provide treatment, whether that’s with a new approach or by altering the current one. SOAP notes and BIRP notes are helpful for clinicians of all kinds, and how you choose to document your patient visits may depend on what type of healthcare field you’re in. 

How can AI help with BIRP notes?

As with SOAP notes, putting BIRP notes into a patient file or EHR can be a time-consuming process. Most clinicians would rather focus on seeing their patients, but also recognize the importance of accurate record keeping. However, a patient’s record is only as helpful as the information that is in it, and if important parts have been left out, it can create an incomplete picture of the patient and their treatment plan. 

One of the best ways to help providers enter better BIRP notes and allow them to focus on seeing their patients is by implementing an AI system to help. AI scribes are making their way into more and more appointments in order to help track important data and keep information organized and easily accessible. Should you consider implementing an AI system to improve BIRP notes and take a time-consuming task off the plate of providers?

Let’s take a look at the advantages of doing that.

The benefits of incorporating AI into BIRP notes

Is adding an AI scribe to help with BIRP notes right for your practice?

If you’re interested in learning more about how AI can help with BIRP notes, you should first weigh the advantages and disadvantages of upgrading to this type of system. There are plenty of facilities that have already incorporated this technology and have gotten great results, but you should first understand that AI is meant to help streamline a healthcare experience, and not replace what a professional provider does. While there are limits on what AI can do, it can definitely assist with routine tasks such as BIRP notes through advanced natural language processing and algorithms. 

AI scribes will “listen” during the patient encounter and can make additions and adjustments to BIRP notes as the session progresses. They interact with patient EHRs so that patient data is always up to date and ready to view. AI for BIRP notes can also use data that you transcribe or dictate and organize the information according to a note template. Keep in mind that a clinician will still need to review what was transcribed for accuracy.

But what are some of the positives you can expect when AI assists with BIRP notes?

• Saves clinicians time. One of the biggest perks of having an AI system to rely on for BIRP notes is that it is a major time saver. Providers are busy enough without having to worry about spending extra time implementing their notes after a session or at the end of the day. AI for BIRP notes is designed to help them get this time back to not only prevent rushed or incomplete notes, but avoid burnout. With a little extra time each day, clinicians can easily incorporate more time for breaks or to spend with their current patients and not necessarily add more appointments to their schedule. 

• Standardizes notes for a professional appearance. Because the notes are inputted by AI, providers no longer need to worry about whether or not their notes have the right organized in the right way. Standardizing the process of BIRP notes ensures that all the same information is collected and that any gaps are filled in or brought to the attention of the provider. This gives a professional appearance and makes finding specific information in notes much easier and quicker.

• Reduces errors. While AI is not above making errors, the likelihood is much smaller than if a human were doing it. AI learns to recognize language and what goes where the more that it is used. It can even develop prompts to finish a query or statement if a provider tends to use similar language over the course of seeing many patients. 

• Improves patient care. Clinicians want their primary focus to be about listening to the concerns of patients and ensuring that their treatment plan is set up to meet their goals. This involves having in-depth conversations and examinations. Providers should not need to worry about typing notes as they go, or relying on their memory at the end of the day to add in BIRP notes. Having an AI system that can be turned on during the session is a great help to those doctors who want to be more present with patients, but still want the level of detail and accuracy they would expect to find in their best written BIRP note. Perhaps AI can assist with that!

Another option offered by a lot of AI systems is to dictate what happened in the session in your own words, and it will populate the BIRP note template with all the required information exactly where it should be.

• Ensures security of patient data.  The security of patient data is essential in any field of healthcare, and steps must be taken to prevent data breaches and cyber attacks. Most AI scribes do not retain the personal information they transcribe, and when the data is sent to the patient’s EHR, it is important that it’s encrypted both during transfer and at rest. There are plenty of AI systems for BIRP notes that offer this level of security.

What are the best AI systems for BIRP notes?

A lot of AI scribes offer a free trial of their software so you can find one that best suits your needs. It’s best that you search for one that is HIPAA compliant, and offers the type of input you want (recording, dictation, direct text descriptions), and does not retain patient information after the session is over.

If you work in the mental health field, consider trying:

• Mentalyc
• SessionAid

And if you’re in another healthcare field, there are many positive recommendations for:

• Orchid
• Scribesly

Consider using AI to enhance BIRP notes!

If you’re ready to save time and increase the efficiency of your facility, consider implementing an AI system to take care of BIRP notes. When this task is automated, you’ll find clinicians are able to spend more time focusing on patient care. Be aware that there are a lot of options out there, so make sure you find one that best suits your needs.