Writing effective progress notes for family and group therapy sessions
When it comes to family therapy and group therapy, progress notes can become more complex due to the multiple parties involved.
Progress notes are an essential part of any therapeutic process: They serve as a record of what transpired during a session, the clinician's observations, and the client's progress toward their treatment goals. When it comes to family therapy and group therapy, progress notes can become more complex due to the multiple parties involved, the different dynamics at play, and note writing formats.
In family and group therapy, progress notes must capture the essence of interactions among participants while focusing on the identified patient. The identified patient is the individual whose insurance is being billed, and their progress is central to the documentation.
This article outlines best practices for writing progress notes on the Headway platform for family/couples and group therapy (CPT codes 90847 and 90853) using the SOAP note format and considerations for the identified patient — the person whose insurance is being billed. It also describes when to use family/couples therapy CPT codes.
Subjective: The client's subjective concerns, symptoms, and any information that the client provided about their condition, personal experiences, and feelings.
Objective: The therapist's observations, including behaviors, interactions, and non-verbal cues.
Assessment: The therapist's interpretation of the session, including any diagnoses or clinical impressions and interventions.
Writing progress notes for family therapy and group therapy requires a balanced approach that focuses on the identified patient while capturing the broader dynamics at play. By using the SOAP note format, therapists can create clear, concise, and meaningful documentation that reflects the therapeutic journey and provides valuable insights for ongoing treatment.
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How to write a progress note for family therapy, with examples
Family therapy involves multiple family members, each with their own dynamics and contributions to the therapeutic process. When writing progress notes, focus on the identified patient while capturing the interactions and impact on the family as a whole.
Documentation for family therapy should follow the basic documentation requirements of a progress note, and meet the requirements for billing with a 90847 CPT code.
Subjective
Begin with the identified patient's account of their feelings, thoughts, and experiences during the session. Include any statements made by other family members that are relevant to the identified patient's perspective.
Note examples:
"The identified patient (John) expressed feeling overwhelmed by his family's expectations. "
"John's sister mentioned that she has noticed him withdrawing from family activities."
Objective
Record the therapist's observations, including family dynamics, behaviors, and any notable non-verbal cues. This section should remain objective and fact-based.
Note examples:
"John avoided eye contact with his parents during most of the session."
"His mother became visibly emotional when discussing family traditions."
Assessment
In this section, interpret the events of the session and assess their impact on the identified patient, including diagnoses or clinical impressions and interventions used during the session.
Note examples:
"John's withdrawal appears to be linked to a fear of disappointing his parents. He noted feeling depressed for several days, anhedonic, lethargic, and sleeping more than usual.”
"This therapist utilized circular questioning from systemic family therapy to encourage family members to think about their shared connections. The family's willingness to discuss sensitive topics indicates a growing level of trust."
Plan
Outline the plan for future sessions.
Note examples:
"Next session, we will explore John’s interests and work on setting boundaries. Follow up in 1 week."
"Recommend family members practice active listening techniques at home. Follow up in 2 weeks."
How to write a progress note for group therapy, with examples
Group therapy involves a collective dynamic among participants. Progress notes should focus on the identified patient's experience within the group context while recognizing the broader group dynamics. A group note should be written for each member of the group.
Documentation for group therapy should follow the basic documentation requirements of a progress note, and meet the requirements for billing with a 90853 CPT code.
Subjective
Start with the identified patient's subjective account of their experiences and interactions within the group. Include statements from other group members that relate to the identified patient.
Note examples:
"The identified patient (Maria) shared that she feels more accepted in the group."
"Maria mentioned that she’s learning to express her emotions more openly."
Objective
Describe the therapist's observations of the group dynamics and the identified patient's behavior during the session.
Note examples:
"Maria actively participated in the group discussion, offering support to other members."
"She appeared relaxed and engaged throughout the session."
Assessment
Interpret the identified patient's progress in the context of the group. This might involve noting changes in behavior, attitude, or communication skills. This would also include any therapeutic techniques used during the group session.
Note examples:
"Maria's increased participation suggests improved confidence and social skills. The group ’s cohesion allows for this therapist and group members to actively show unconditional positive regard."
"Her supportive behavior indicates growth in empathy and relational skills."
Plan
Outline the next steps for the identified patient's treatment within the group therapy context. This could include specific group activities, individual assignments, or additional sessions.
Note examples:
"Continue to encourage Maria to share her experiences with the group. Follow up group to meet in 1 week"
"Next session, focus on exploring coping strategies for social anxiety. Follow up group to meet in 2 weeks."
90847 vs. 90837: How to distinguish between family/couples therapy and individual therapy (with an additional person present).
It can be challenging to differentiate between family/couples therapy and individual therapy with an additional person present; the latter documented with CPT codes like 90832, 90834, and 90837 depending on session duration.
The difference depends on factors like:
Participants
Nature of the interaction
Content of the session
Goals
Documentation
To help you know when to use the appropriate code, Headway has created a guide for weighing each factor and making a sound decision about which codes to use.
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