Working through your struggles supported by others with similar challenges can be powerful. The practice of giving and receiving help tends to bring out the best in us. After all, we’ve been working through challenges together in groups as a species for as long as we’ve been walking on two legs.
Writing progress notes for group therapy can pose unique challenges, however, especially if you’ve just begun with clients in a group setting. This post will unpack how group therapy and individual therapy notes work together and explain the individual components of a group therapy note. We’ll wrap up with four tips for writing better group therapy notes that you can put into practice today.
Group therapy notes have two components. First is the group note. A group therapy note describes the group’s progress and dynamics as a whole and doesn’t name specific individuals due to privacy reasons. While some insurers may accept a general group note when billing for group therapy services, most require an individualized group therapy note for each client alongside the general note.
While writing an individualized group therapy note for everyone in your group may feel daunting, you can streamline the process. You’ll follow your preferred format for individual therapy note-taking. Here’s what you’ll need for each component.
As stated, the group summary includes basic information on the group. List the group name, main topic(s) covered during the session, interventions you implemented, and the schedule. Since this section will be the same for each client, you can copy and paste this into everyone’s individualized note.
In the individualized portions, it’s important to document how the client engaged within the group. Include information like their level of active engagement, contributions, and reactions. For example, are they seen as a leader, or do they assume a more passive role in the group’s dynamics?
In this section, detail how the group reacted to the client. Were they welcoming and receptive, or did the group struggle to accept and integrate the client into the discussion?
Each group has its own unique dynamics. And each member exerts an influence on how the group functions as a whole. Detail how the client influenced the group. Did they have a significant pull on the direction of the discussions, affecting the tone of the interactions in a marked way?
Group dynamics work both ways. In this section, you’ll note how the group affected the client. Did the group’s consensus on a particular topic seem to hit home and exert a noticeable change in the client’s way of thinking about the issue? Were they more excited about the possibility of change due to the encouragement they received from the group?
Read Tips for Writing Mental Health SOAP Notes to learn more about writing effective individual progress notes.
Quality therapy notes not only decrease the chances of insurance denials, but they also help you keep closer tabs on each client’s progress, making you more effective as you plan for future interventions. Whether you’ve written group therapy notes for decades or you’re relatively new to group therapy, here are four time-tested tips that will help you write clearer, more informative group therapy notes.
Some clients make this easier than others. If you have a client in a group with a strong personality or difficult demeanor, seeing them through an objective lens can be challenging. After all, you’re human. But as you’re describing a client’s interactions within the group, be careful to avoid any language that may come across as judgemental. Report just on what’s objectively observable, avoiding recording any opinions or feelings that aren’t rooted in fact. Be mindful of any biases you may have towards certain clients and take extra precautions to stay objective as you write their summaries.
Individualized group therapy notes should only include identifiable information for the client you’re writing about. As you’re describing group dynamics and how the client interacted with and was influenced by others, be careful not to include any identifiable information about other group members. If you’re documenting an interaction the client had with another group member, never use names, even first name. Describe the other individual in generic terms to ensure you protect their confidentiality.
Best practice for every progress note is to write it so that another therapist has enough information to pick up right where you left off. Therapy notes are useful for documenting current progress and planning for future interventions. They also form a historical record of the client’s therapy experiences over time. As you write group notes, be as detailed and explicit as possible. Remember that although you know important details and background on the client, valuable insight will be lost if you don’t put it down on paper. As a secondary benefit, the more clear and concise your progress notes are, the less likely your billing claims will be denied or delayed over an insurer’s request for additional information. And if you’re audited, well-written progress notes are your best friend.
A group session usually focuses on a single theme. For example, a session for a group of clients struggling with substance abuse disorder may focus on identifying triggers that increase the likelihood of experiencing a relapse. After discussing potential triggers, you present a general plan for avoiding relapse, and each group member crafts a plan unique to their needs. As a general rule, clearly state your actions and guidance as the group leader and any therapeutic interventions you provided during the session in every individualized group therapy note.
Group therapy represents an empowering way to help clients move past their presenting problems by leveraging the help and support of others. Accurately recording each client’s progress in relation to the group dynamics not only streamlines insurance billing but makes it easier to plan for their needs in future group or individual therapy sessions.
Read The Comprehensive Guide to Effective Therapy Progress Notes to learn more about creating treatment plans and progress notes.