Group Psychotherapy Progress Note

Patient Name: [Patient full name]

MRN/DOB: [MRN] / [DOB]

Date of Service: [Date]

Start Time / End Time: [Start hh:mm / End hh:mm] (If end time unavailable, note "End time not captured; duration estimated at [__] minutes")

Service Type: Group Psychotherapy

Modality: [in-person / video / audio-only / mixed]

Facilitator(s): [Name, credentials; co-facilitator if applicable]

Diagnosis Focus: [Primary diagnosis/condition supporting medical necessity]

Treatment Plan Goal: [Individualized goal targeted this session]

Group Session (Common Content)

(This section must be non-identifying and appropriate to appear in every participant's chart. Do not include names or details that could identify other participants.)

Attendance: [__ of __ enrolled present; late arrivals/early departures as counts only] (Note if session ran full scheduled time.)

Theme/Topic: [Clinical focus and therapeutic frame in 1–3 sentences] (Identify skill/topic and approach—e.g., CBT cognitive restructuring, DBT mindfulness, relapse prevention, process-oriented exploration. If manualized, include module/skill name.)

Interventions: [Clinician actions demonstrating active psychotherapy] (Document psychoeducation provided, skills introduced/practiced, process interventions such as eliciting feedback or reflecting patterns, and homework reviewed/assigned. Focus on what the clinician did, not individual member responses.)

Group Process: [Overall engagement level; affect/tone; notable dynamics] (Example: "Moderate engagement; supportive discourse; themes of [X]; brief rupture/repair around [Y]." Keep non-identifying.)

Confidentiality/Norms: [Content reviewed] (Include only if reviewed this session—e.g., confidentiality reminder, safety norms, new member orientation. Omit entirely if not performed.)

Individual Patient Addendum

(Complete the following individualized elements for this patient only. Do not include other members' content or quotes.)

Attendance/Participation: [present / late by __ min / left early by __ min]; [active / moderate / minimal / silent-but-attentive] participation (Include at least one concrete behavioral anchor—e.g., "shared two triggers," "completed role-play," "did not verbalize but maintained engagement.")

Response/Progress: [Patient-specific themes addressed; response to interventions; skill practiced; insight or affect change; progress toward individualized treatment goal] (Include brief MSE observations only if notable. If no meaningful change, document "stable" with brief supporting statement.)

Risk Assessment: [SI/HI status; protective factors; actions taken] (Include only if assessed this session or concerns arose. If not assessed and no acute cues observed, may note: "No acute risk cues; will reassess PRN." Omit entirely if not clinically indicated.)

Plan: [Individualized home practice assigned or "none assigned"; focus for next session; follow-up needs such as individual session, medication management, referrals, or care coordination]

Clinician Signature: [Electronic signature]

Credentials: [Credentials and license]

Date/Time Signed: [Date and time]