Notes written by counselors for group sessions serve a few different purposes. The primary purpose of group counseling notes is to help the client and keep track of his or her progress toward meeting treatment goals. These notes are also used to document a client’s use of services for payment purposes, generally from insurance companies. Group counseling notes can also be used to help treatment teams communicate with one another about a client's progress.
Learn the guidelines for the organization in which you are running the group. Specific requirements for group notes vary depending on the setting. Some organizations require a single note, written directly after the group meets, summarizing what occurred in the group overall. Other organizations require that notes are written for each individual who participated in the group, as well as a summary of what was accomplished in the group that day. (See References 1 and 2.)
Provide basic information about the group. Most organizations provide a template of information required by the counselor. Be prepared to supply the name of the group, the time and duration of the meeting, names of group facilitators, the group’s schedule, and the number of clients in attendance that day. Give an overview of the type of group (for example, if it was an open psychotherapy group or a more directive educational group). (See References 2 and 3.)
Explain specific therapeutic interventions used in the group, and why. Interventions vary widely depending on the type of group and the problems with which group participants are struggling. In a substance abuse group, for instance, a common intervention is to discuss the circumstances that trigger participants’ desire to use substances. (See References 1 and 2.)
Describe the progress made by each individual towards his or her treatment goals. Provide a brief assessment of the client. Describe her appearance that day, her participation (Did she participate and to what extent?) and comment on any significant changes in behavior you observed or challenges that she discussed. Include recommendations for future treatment. (See References 2 and 3.).
Use language that is objective and focuses on the client’s behavior. Try to make your notes clear, succinct and devoid of judgments or opinions.
Write notes about individual clients separately to ensure client confidentiality. For instance, do not include information about specific client names in a note about the group in general. Rather, provide this information in notes that are specific to the individual’s progress.