BIRP Note Example

Trauma from Medical Procedures

Client is processing trauma related to past medical procedures.

Generated BIRP Note:

Quill generated this note with AI from the summary that was provided. The therapist can then copy-and-paste the note into their current EHR platform.

Behavior:
Client presented with increased anxiety, particularly related to recurring memories of a past medical procedure. Client stated 'I just shut down whenever I think about it' and reported physical symptoms such as tension, racing heart, and shortness of breath when recalling the event. The impact of medical trauma on their well-being was discussed.

Intervention:
A 45-minute office session focused on teaching the client a grounding technique. The therapist guided the client through a five senses exercise to help manage overwhelming feelings associated with their memories.

Response:
Client engaged with the grounding exercise, demonstrating a reduction in anxiety by the end of the practice. They appeared to relax and showed interest in continuing to use the technique as homework.

Plan:
Client was assigned to practice the grounding technique as homework. The next session is scheduled for next week, with the intention to review the effectiveness of the technique and potentially explore deeper emotional responses related to the trauma.

Client Session Summary:

Here's the summary of this client session. Remember, Quill does not record the client session. A therapist would provide a summary (like the one below) after the session is over.

We had a 45-minute office session today, and the client came in looking pretty anxious, talking about how memories from a past medical procedure have been coming up more and more lately. They said quote 'I just shut down whenever I think about it' unquote and described how it’s affecting them physically, too—like they get tense, their heart starts racing, and they feel like they can’t breathe. We talked about how medical trauma can sometimes be just as intense as other types of trauma, even though people don’t always recognize it that way.

We spent some time going over a grounding technique that could help them stay present when those memories come up, because they’ve been feeling pretty overwhelmed. I walked them through the five senses grounding exercise—focusing on what they can see, hear, touch, taste, and smell to bring them back to the present. They seemed to relax a bit once we practiced that. Their homework is to try using that technique whenever they feel those memories creeping up, just to see if it helps them stay grounded. By the end of the session, they seemed a little more at ease, like they finally had something concrete to try. We’ll meet again next week to see how it’s going and maybe start digging into some of the deeper emotional stuff after they’ve had a chance to try out the grounding.

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