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Documenting Medical Necessity for Psychotherapists

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Documenting Group Therapy

To say that running groups is both challenging and rewarding is like saying that you love to cook but hate to clean up afterwards. The difference is that you can get others to clean up but you still need to write your own notes.

REWARDS OF RUNNING GROUP THERAPY

There’s truly something magical about facilitating a group. It multiplies your impact over providing one-on-one therapy. You get to watch the group dynamic evolve over time. At first, guarded and hesitant, the process of trusting others, opening up, sharing struggles, and offering and accepting support can be life changing. Guiding and witnessing the process of forging bonds and making positive changes is more satisfying than eating a delicious meal.

CHALLENGES OF RUNNING GROUP THERAPY

Providing group therapy is also a lot more work than anyone ever anticipates. The time spent developing the group, creating the structure, enrolling it, prepping for the sessions, facilitating it, and documenting the process leaves a lot on your plate. Unfortunately, documenting a group member’s progress is an unwelcome afterthought – if documentation even gets a place on the table.

I have led a lot of therapy groups in my 30 years as a therapist, starting as intern in an inpatient unit in a hospital. No one ever asked to see my notes and I never wrote one – not my supervisor, a hospital administrator, the insurance company, or a patient. Maybe it’s because if a patient qualified for the hospital program, they qualified for the group. In other words, documenting group therapy wasn’t necessary to justify their stay in the hospital. Maybe it’s because litigious clients were not as plentiful as they are today. Maybe it’s because my supervisor was overworked and underpaid. Maybe documenting group therapy simply wasn’t required back then.

I can’t go back in time to find out why I wasn’t taught to write notes, but I was lucky, and so was the hospital, that it never resulted in legal issues. No one ever complained about my leadership so “if it wasn’t documented it didn’t happen” didn’t play out as a problem.

Ten years later, I developed and co-led multiple 12-week groups with another therapist. We alternated leading weekly sessions. Our intention for note writing was to keep each other informed of what happened the previous week. It was much like keeping the “memory notes” I talk about in my Misery or Mastery®: Documenting Medical Necessity for Psychotherapists training. At the top of the page on a yellow legal pad, we wrote the date and group topic. The body of “the note” contained comments about every group member’s participation. If someone requested to see our notes for one client, they could have seen the notes on all group members. Fortunately, that never happened. Our intentions were noble, but our process was flawed.

Maybe back then documenting group therapy wasn’t required. But it is now. And there are guidelines for what and how much to write.

GUIDELINES FOR DOCUMENTING GROUP WORK

Whether the group is covered by insurance or not, a group therapy note must be written for each member of the group. Writing individual notes takes longer but it’s clinically and ethically appropriate, as well as legally required. Two main reasons for writing individual notes stand out:

  1. Confidentiality: The Cures Act applies to group notes. Clients, other providers, and collaterals can have access to the note. Writing a group note that includes private and confidential information of every member violates HIPAA. Keeping notes specific to each client ensures that their private health information is protected.
  • Client centered: An individual note for each group member ensures client-specific documentation. It means the documentation reflects how the session impacts the unique needs, goals, and progress of the individual client.

Notes must capture essential clinical information while ensuring compliance with professional standards. Many of the requirements for an individual session apply to the group note.

General progress note requirements include:

  1. The diagnosis: if you bill insurance, you must provide a diagnosis.
  2. Risk
  3. Mental status
  4. Interventions
  5. Client response to the group
  6. Client’s progress: what did the client do that was different this session from last session?
  7. Next session date

Specific group note requirements include:

  1. Group topic
  2. Group goal
  3. Engagement
  4. Participation type and level

Group therapy is a powerful experience for both the clients and the therapist. For clients it fosters connection. Out of connection comes change. For therapists it provides an opportunity to make a broader impact. Documentation in group therapy can be challenging, but with the right strategies, it’s manageable and well worth the rewards.

Fulfilling group therapy documentation requirements can be time consuming and complex without the right template. The Documentation Wizard Group Therapy Note will streamline your documentation with checkboxes and very short narratives that cover all the requirements. It has been approved by an attorney and a bioethicist as well as being peer reviewed and approved by a prior standing board member of the APA, You’ll be able to document each participant’s experience quickly and easily so you can enjoy the accomplishment of running your group.

But let’s focus on what we do like. If you run group therapy, what’s your favorite part of the process?

Beth Rontal, LICSW, a private practice therapist and the Documentation Wizard® is a nationally recognized consultant on mental health documentation. Her Misery and Mastery® trainings and accompanying forms are developed to meet strict Medicare requirements. Beth’s Documentation Wizard® training program helps clinicians turn their clinical skill and intuition into a systematic review of treatment that helps to pass audits, protect income, maintain professional standards of care, reduce documentation anxiety and increase self-confidence. Beth’s forms have been approved by 3 attorneys and a bioethicist and have been used all over the world. She mastered her teaching skills with thousands of hours supervising and training both seasoned professionals and interns when supervising at an agency for 11 years.