How do you record your recovery group notes in the medical record?

Therapists use a group note template that includes the date, number of participants, topic of group, summary quote from program member, and note if a relapse with what substance has occurred. See below for an example from our electronic medical record (Athena).


In the Recovery Program

Patient was seen on _____ for a 90 minute group session. There were _____ participants present. Patient is cognitively appropriate for group therapy. The patient has the capacity to understand, participate and benefit from treatment.

The group topic was __________. Goals were discussed to achieve a solid, abstinent, recovery.

The patient’s contribution to today’s intervention was:
________________________________________

The group responded: [drop down box]

  • positively; or
  • negatively

The patient reported: [drop down box]

  • remaining abstinent; or
  • relapsing drug used identified

Follow-up in 1 week for ongoing Recovery Group Therapy services for behavior modification and maintenance in relapse-risk reduction.