What ICD-10 codes should I use for bipolar disorder in progress notes?

Bipolar disorder uses the F31.x code family. Common codes include: F31.0 (bipolar I, current episode hypomanic), F31.11 (bipolar I, current episode manic without psychotic features), F31.31 (bipolar I, current episode depressed, mild), F31.32 (bipolar I, current episode depressed, moderate), F31.4 (bipolar I, current episode depressed, severe without psychotic features), F31.71 (bipolar I, in partial remission, most recent episode depressed), F31.75 (bipolar I, in full remission), and F31.81 (bipolar II disorder). Update the code as the current episode changes — a client who shifts from depressive to hypomanic requires a code change, and the clinical reasoning should be documented.

How do I document a therapy session during a manic or hypomanic episode?

During manic or hypomanic episodes, document the presenting features (elevated or irritable mood, decreased need for sleep, pressured speech, grandiosity, increased goal-directed activity, impulsivity), the client's level of insight into the episode, any risky behaviors reported, and the specific interventions used (psychoeducation about mania recognition, harm reduction for impulsive behaviors, sleep hygiene reinforcement, medication adherence review). Note whether you contacted the prescriber to report mood elevation. Document the client's self-reported mood rating and your clinical observation of the mood state, as these often diverge during mania — the client may feel 'great' while you observe pressured speech and psychomotor agitation.

Should I use the PHQ-9 for bipolar depression or a different measure?

The PHQ-9 can be used to track depressive symptom severity during bipolar depressive episodes, but it does not capture manic or hypomanic symptoms. For comprehensive bipolar monitoring, use a mood charting system that tracks both poles. The Internal State Scale (ISS) or the Altman Self-Rating Mania Scale (ASRM) can supplement the PHQ-9 by capturing hypomanic and manic symptoms. Many clinicians use a simple daily mood chart (1-10 scale with 5 as euthymic) plus the PHQ-9 during depressive episodes and the ASRM when mood elevation is suspected.

How do I document medication adherence without overstepping my scope as a therapist?

As a therapist, you can and should document the client's self-reported medication adherence, barriers to adherence, and any side effects they report. Write it as client report: 'Client reports taking lithium 900mg and lamotrigine 200mg as prescribed. Reports adherence has been consistent this week. Denies side effects.' If the client reports non-adherence, document the reported reason, any psychoeducation you provided about the importance of mood stabilizers, and whether you recommended they contact their prescriber. Note any coordination of care: 'Therapist contacted Dr. Reyes by secure message to report client's report of medication non-adherence and emerging mood elevation.' This documents your clinical responsibility without practicing outside your scope.

How should I document when a client is euthymic between episodes?

Euthymic periods are an opportunity to document maintenance and relapse prevention work. Note the euthymic mood state explicitly: 'Client presents as euthymic — mood is stable, affect is full range and congruent, sleep is regular (7-8 hours), and no manic or depressive symptoms are endorsed.' Document the maintenance interventions delivered: relapse prevention planning, early warning sign identification, routine and rhythm maintenance, interpersonal effectiveness skills, and psychoeducation reinforcement. This documents ongoing medical necessity during stable periods by showing that therapy is actively preventing relapse.

Progress Notes for Bipolar Disorder: Documentation Guide

Progress Notes|11 min read|Updated 2026-03-19|Clinically reviewed

What Are Progress Notes for Bipolar Disorder?

Progress notes for bipolar disorder are session-level clinical records that document the psychotherapeutic treatment of Bipolar I and Bipolar II Disorder using mood-episode-specific language, systematic mood monitoring, and evidence-based bipolar interventions. These notes differ from general mood disorder documentation because they must account for the cycling nature of the illness — tracking not just current symptom severity but the phase of illness (depressive, manic, hypomanic, mixed, or euthymic), transitions between phases, early warning signs of episode onset, and the client's ongoing relationship with medication adherence.

Effective bipolar disorder progress notes document the specific therapeutic work being done within the context of the current mood state. A session during a depressive episode looks fundamentally different from a session during euthymia or emerging hypomania, and the documentation should reflect this. Notes must also capture the coordination of care with prescribers, as pharmacotherapy is a cornerstone of bipolar treatment and the therapist plays a critical role in monitoring medication adherence, identifying early signs of mood shifts, and communicating concerns to the treatment team.

When You Need Diagnosis-Specific Notes

When treating a client with Bipolar I Disorder (F31.x) or Bipolar II Disorder (F31.81) in any phase of illness
When documenting psychotherapy that complements pharmacotherapy for bipolar disorder
When a client's mood state shifts between sessions and you need to document the phase transition and your clinical response
When insurance requires evidence that therapy for bipolar disorder addresses specific treatment targets beyond medication management
When coordinating care with a psychiatrist or prescriber and needing to document mood observations that inform medication decisions
When establishing medical necessity for therapy during euthymic periods (relapse prevention and maintenance)
When a client presents with mixed features, rapid cycling, or treatment-resistant patterns that require detailed clinical tracking

Key Components — What to Document

Current Mood Phase Identification

Every bipolar disorder progress note should clearly identify the client's current mood phase and any evidence of transition:

Depressive phase: document depressive symptoms using the same specificity as MDD notes — dysphoric mood, anhedonia, neurovegetative symptoms, psychomotor changes, hopelessness, suicidal ideation
Hypomanic phase: document elevated, expansive, or irritable mood; decreased need for sleep; increased energy and goal-directed activity; pressured speech; increased talkativeness; distractibility; impulsivity — with notation that the client may have limited insight
Manic phase: document the above plus severity indicators — functional impairment, psychotic features if present, risk behaviors, need for higher level of care assessment
Mixed features: document the co-occurrence of depressive and manic/hypomanic symptoms, which often represents the highest-risk presentation
Euthymia: document stable mood, absence of episode criteria, and the maintenance work being done to sustain stability

Mood Monitoring Data

Document the client's mood tracking systematically:

Daily mood ratings (scale used, range this week, trend direction)
Sleep duration and quality (a critical early warning indicator for mood shifts)
Energy level changes
PHQ-9 scores during depressive episodes
Altman Self-Rating Mania Scale or clinician-observed signs during mood elevation
Any mood charting or life charting data reviewed in session

Medication Adherence and Side Effects

Document the client's self-report of medication status at every session:

Current medications, dosages, and prescriber
Adherence this week (fully adherent, partially adherent, non-adherent)
Barriers to adherence (side effects, cost, ambivalence, feeling "better" and wanting to stop)
Side effects reported
Any changes made by the prescriber since last session
Any coordination of care initiated by the therapist

Phase-Appropriate Interventions

Document interventions that match the current mood phase:

During depression: behavioral activation, cognitive restructuring targeting hopelessness, activity scheduling, sleep regulation, suicidal ideation assessment
During hypomania/mania: psychoeducation about episode recognition, harm reduction for impulsive behavior, sleep hygiene reinforcement, stimulus reduction, medication adherence support, prescriber notification
During euthymia: relapse prevention planning, early warning sign identification, Interpersonal and Social Rhythm Therapy (IPSRT) elements, routine stabilization, psychoeducation about the illness
During mixed episodes: safety assessment, crisis planning, prescriber coordination, stabilization, avoid activating interventions

Risk Assessment — Elevated Importance

Bipolar disorder carries significant suicide risk, particularly during depressive and mixed episodes. Document suicidal ideation, plan, intent, and means assessment at every session. Also assess for reckless and impulsive behavior during mood elevation (financial, sexual, legal risks), substance use, and medication non-adherence as a risk factor for destabilization.

SOAP Note — Psychotherapy Session for Bipolar I Disorder (Depressive Phase)

S — Subjective: Client reports "I'm sinking again — I can feel it pulling me down." States mood has been "flat and heavy" for the past 10 days, worsening over the past 3-4 days. Reports sleeping 10-11 hours per night but waking unrefreshed, compared to her baseline euthymic sleep of 7-8 hours. Appetite is decreased — reports eating one meal per day and having to force herself to eat. Describes anhedonia — "I cancelled dinner with my friend because I couldn't imagine caring about it." Reports she has stopped her morning walking routine for the past week. States she is continuing to take her medications as prescribed: lithium 900mg and quetiapine 200mg, prescribed by Dr. Reyes. Denies side effects. Reports passive suicidal ideation — "I had the thought that it would be easier if I just didn't wake up, but I wouldn't do anything." Denies active suicidal ideation, plan, or intent. Denies self-harm urges. Reports no alcohol or substance use. States she recognized the mood shift early because of the sleep changes and increased isolation — "I know this pattern, I just feel powerless to stop it."

O — Objective: Client arrived on time, wearing the same outfit as last session (atypical — client typically presents well-groomed). Psychomotor retardation was evident — slowed gait, latency in responding to questions (2-3 seconds), reduced gestures. Affect was flat with constricted range. Tearfulness noted when discussing social withdrawal. Eye contact was intermittent and downcast. Speech was soft and slow in rate with reduced spontaneity. Thought process was linear but impoverished — client provided brief responses and required prompting. No psychotic features observed. Mood chart reviewed — self-rated mood has declined from 5/10 (euthymic) to 2-3/10 over the past 10 days. PHQ-9 administered: score 17 (moderately severe), up from 6 at session 12 (during euthymic phase). Sleep log reviewed — average 10.5 hours per night with hypersomnia pattern developing. Psychoeducation provided about the depressive episode within the context of bipolar cycling — normalized the client's experience while reinforcing the importance of maintaining behavioral routines despite low motivation. Behavioral activation exercise conducted — identified three low-effort activities client can schedule this week (10-minute walk, texting her friend, preparing one simple meal). Safety planning reviewed and updated — client confirmed her safety plan is accessible and identified her sister and Dr. Reyes's crisis line as contacts. Therapist contacted Dr. Reyes via secure message during session to report the depressive episode onset and passive suicidal ideation.

A — Assessment: Client is experiencing a moderate depressive episode within the context of Bipolar I Disorder, representing a shift from the euthymic state documented at sessions 11-13. The onset pattern is consistent with her historical episode signature: hypersomnia as the earliest indicator, followed by social withdrawal and anhedonia, then psychomotor retardation and passive suicidal ideation. The client's ability to recognize this pattern early reflects the psychoeducation and self-monitoring work done during euthymic sessions. PHQ-9 increase from 6 to 17 over approximately 3 weeks confirms a clinically significant mood decline. Current medication regimen appears insufficient to prevent the depressive episode; coordination with Dr. Reyes is appropriate. Passive suicidal ideation is present without plan, intent, or means — consistent with the client's historical pattern during depressive episodes. Protective factors include treatment engagement, medication adherence, early episode recognition, social support (sister), and absence of substance use. Risk level: moderate, elevated from low during euthymic phase. Safety plan reviewed and intact. Diagnosis updated: Bipolar I Disorder, current episode depressed, moderate (F31.32). Prognosis: Fair — client has historically responded to medication adjustment combined with behavioral activation during depressive episodes.

P — Plan:

Increase session frequency to twice weekly during depressive episode (request authorization for additional sessions)
Behavioral activation — client will complete at least one planned activity per day from the list generated in session, tracking completion and mood impact
Continue daily mood and sleep charting
Reinforce social rhythm stability — maintain consistent wake time (set alarm for 8:00 AM) even when hypersomnia urges are present
Coordination of care: Dr. Reyes notified of depressive episode and passive suicidal ideation via secure message; therapist will follow up to discuss potential medication adjustment
Safety plan reviewed and updated — client has copy in her phone; sister identified as primary support contact
Assess suicidal ideation at each session; if active ideation with plan or intent develops, implement crisis protocol
Continue lithium 900mg and quetiapine 200mg as prescribed — monitor for any changes from Dr. Reyes
Next session: 03/21/2026 at 1:00 PM (increased frequency)

This is a sample for educational purposes only — not real patient data.

Clinical Language and Interventions to Document

Diagnosis-Specific Terminology

Instead of "client's mood is up and down" write "client reports mood instability with a depressive shift over the past 10 days, transitioning from euthymic baseline (5/10) to depressed (2-3/10) with hypersomnia, anhedonia, and psychomotor retardation"
Instead of "client is sleeping a lot" write "client reports hypersomnia (10-11 hours per night, up from baseline 7-8 hours), consistent with early depressive episode onset per client's historical mood episode pattern"
Instead of "client seems hyper" write "client presents with features suggestive of emerging hypomania — reported decreased need for sleep (4 hours, feeling rested), increased goal-directed activity (started three new projects), pressured speech observed in session, and elevated/expansive affect with grandiose quality"
Instead of "client stopped taking medication" write "client reports medication non-adherence — discontinued lithium 3 days ago, citing side effects (tremor, weight gain) and feeling 'fine without it.' Psychoeducation provided about destabilization risk. Coordination with Dr. Reyes initiated."
Instead of "client is stable" write "client presents as euthymic — mood self-rated 5/10, affect is full-range and mood-congruent, sleep is regular (7.5 hours), energy is within normal limits, no manic or depressive symptoms endorsed, and social and occupational functioning is intact"

Interventions to Name and Describe

Psychoeducation about bipolar disorder: "Provided psychoeducation about the bipolar depressive episode cycle, including the role of sleep disruption as a trigger and early warning sign. Client demonstrated understanding by identifying her own sleep-mood pattern from the mood chart."
Interpersonal and Social Rhythm Therapy (IPSRT): "Reviewed the Social Rhythm Metric. Client's routine regularity has decreased over the past week (meal times, wake times, and social contacts are less consistent). Collaboratively identified two anchor routines (wake time and dinner time) to stabilize this week."
Mood monitoring and life charting: "Reviewed the client's mood chart from the past two weeks. Identified a pattern of mood dipping 2-3 days after disrupted sleep. Client added sleep quality as a tracked variable to increase early warning detection."
Medication adherence support: "Explored ambivalence about continuing mood stabilizer using motivational interviewing techniques. Client identified the pros of stability (keeping her job, maintaining her relationship) and the cons of discontinuation (historical pattern of hospitalization within 3 months of stopping medication). Client recommitted to adherence."
Relapse prevention planning: "Updated the client's relapse prevention plan. Reviewed early warning signs for both poles: depression (hypersomnia, social withdrawal, cancelled plans) and hypomania (decreased sleep, increased spending, increased irritability). Client will share the plan with her sister as a designated support person."

Common Mistakes

Failing to identify the current mood phase in every note. Every bipolar disorder progress note should state the current phase explicitly — depressive, hypomanic, manic, mixed, or euthymic. Without this, the note lacks the context needed to understand the treatment approach and the client's trajectory.
Not documenting medication adherence at every session. Medication non-adherence is one of the strongest predictors of mood episode recurrence in bipolar disorder. Document adherence status, barriers, and any psychoeducation or motivational work done around adherence at every session, regardless of the current mood state.
Using the same documentation approach for bipolar depression and unipolar depression. Bipolar depression requires additional documentation: the cycling context, medication status (mood stabilizers, not just antidepressants), sleep-wake patterns as destabilization indicators, and the risk of treatment-emergent mania. A note that reads identically to an MDD note is missing critical clinical information.
Neglecting to document coordination of care with the prescriber. When you observe mood shifts, medication non-adherence, or emerging episode signs, document whether and how you communicated with the prescribing provider. Failure to coordinate care when mood changes are observed is a significant clinical and legal liability.
Not documenting euthymic sessions with clear treatment targets. During stable periods, some clinicians write vague notes because the client is "doing well." Euthymic sessions should document specific maintenance work: relapse prevention planning, early warning sign review, social rhythm stabilization, and psychoeducation reinforcement. This demonstrates ongoing medical necessity during stable periods.