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
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.