Group therapy provides a unique outlet for participants to interact and gain insight from one another, all under the guidance of a counselor. Part of the job as a group therapy counselor is documenting the session and its relation to clients’ treatment plans. Depending on your practice, insurers may require group therapy before they will reimburse you. A group therapy note is also a critical component of each client’s medical record and can enhance their mental health care.
If you’re starting to offer group therapy or considering adding this service to your practice, you may be wondering how to document these sessions. This post will explain what to include in a group therapy note and provide a few tips for writing better notes.
Table of Contents
- What Is a Group Therapy Note?
- The Elements of a Group Therapy Note
- How to Write Better Group Therapy Notes
What Is a Group Therapy Note?
A group therapy note is a type of progress note. It focuses on how a group therapy session helps clients reach their treatment goals and describes their participation. In general, you’ll need to write an individual note for every person who participates in the group therapy session to prove medical necessity and get reimbursed. Each note will start with an overall summary of the group’s discussion topic and the interventions used, followed by the client’s response to the session and how the meeting addressed their treatment goals.
The Elements of a Group Therapy Note
Overall, group therapy notes are not much different than the progress notes you write for individual client sessions. For example, you can use the SOAP (an acronym for Subjective, Objective, Assessment and Plan) note format for individual group therapy notes, just as you would for regular progress notes. The difference is you’ll include a brief group summary at the top of each note and incorporate details about the session throughout the document.
Regardless of the note-writing format you use, be sure to describe the client’s participation in the group, how they reacted to the session and how the meeting addressed their treatment goals.
To help you get started, here are essential elements to include in individualized group therapy notes.
1. Group Summary
Each note for individual clients should begin with a group synopsis. You might include the following details:
- The group’s name
- The discussion topic
- The session’s date
- The session’s start and stop time
- The session’s schedule
- The counselor’s name
- The number of clients in attendance
- The interventions used
You can use the same group summary for each client. If you do so, make sure it does not include individual client’s names. You might create an attendance list and file it in a separate folder.
2. Identifying Information
Ensure each note includes accurate identifying information such as:
- The client’s full name
- The client’s identification number
- The client’s date of birth
- Your organization’s name
Depending on your practice, you may need to include a few other details, such as the client’s gender or contact information.
3. Mood and Appearance
Include the client’s observed or reported mood. Also, note the client’s overall appearance and anything that stands out. You might use a mental status exam checklist to help you describe a client’s mood and appearance.
Did the client participate in the group discussion? Did they share their feelings with others or offer their insights? Note observations you made of each client and how they behaved in group therapy, including their response to other group members and any personal experiences they shared.
5. Issues and Events
Describe any new issues the client presented during the session or problems they had with another group member. For example, if a client becomes angry and argues with another group member, describe how you intervened and helped them identify the source of their anger.
6. Goals and Objectives
Document the goals and objectives in each client’s treatment plan that you addressed during the group therapy session. For instance, imagine a client’s goal is to stop abusing alcohol. They have several objectives in their treatment plan to help them achieve this, such as identifying triggers that lead to their alcohol use. Include this specific objective if the group therapy session focuses on identifying substance use triggers.
7. Therapeutic Intervention
List the interventions you used during the session to target a client’s goals and objectives. For example, you might write that you taught the group a breathing exercise to help members reach their goal of feeling less anxious.
8. Response or Progress
Write how the client responded to the session and whether it helped them get closer to their goals. Include if the session moved the client away from their objectives or made no impact. For example, you might add that a client listened to the group’s feedback but did not seem interested in applying their suggestions. If the client does not eventually make progress, you may want to include how you will change your strategy.
9. Plan and Additional Information
Describe the client’s plan for future sessions and homework you assigned. Use this section to mention if a client will miss the next session and explain why. Include any strategies the client learned during group therapy that they plan to apply while they’re absent.
10. Signature and Date
Include your signature, credentials, time and date. If needed, get your supervisor’s signature as well. You might also add the time and date of the next group therapy session.
How to Write Better Group Therapy Notes
Like individual progress notes, group therapy notes should be accurate, detailed and easy to read. Well-written notes reduce the likelihood that your insurance claims will get denied. They also help you monitor a client’s overall progress and develop effective treatment plans. Here are a few tips to help you write quality group therapy notes.
1. Use Objective Language
Be sure to write your group therapy notes using an objective tone. You don’t want to interject anything that could suggest a bias toward any specific participant. Any opinions need to remain focused on client problems and progress, avoiding wording a reader could interpret as judgmental.
2. Keep Notes Confidential
All clinical documentation must stay confidential to comply with ethical guidelines and the Health Insurance Portability and Accountability Act, including group therapy notes. Ensure each client’s notes do not include the names or other identifying information of other group members.
3. Be Clear and Concise
If multiple professionals are running your group, your notes will be the main element in continually driving progress. Others will need to understand the specifics of past meetings, allowing them to pick up and continue therapy seamlessly. Ensure you have clearly stated your analysis of the current session and that the discussed plan for progress is easy to understand.
Write Streamlined Therapy Notes With ICANotes EHR Software
Group therapy sessions offer a valuable way for those facing similar challenges to find a community of support. As the therapist and moderator of group therapy sessions, your ability to accurately document each client’s behavior and progress will help them become who they want to be. Implementing a thorough method for recording group notes plays a significant role in the process.
ICANotes’ electronic health record software can help behavioral health professionals take customized, comprehensive group therapy progress notes efficiently and accurately. To learn more about how our therapy software can help you create better notes in less time, contact our team at 866-847-3590 today or request your free trial to get started.
Last updated May 21, 2021.