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Group Therapy SOAP Notes: Complete Documentation Guide for 2026

Updated January 2026

Group therapy documentation presents unique challenges: you must capture individual patient progress while documenting collective group dynamics. Recent regulatory updates emphasize individualized documentation for each participant. This guide covers best practices for group therapy SOAP notes that meet clinical, legal, and billing requirements.

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2025-2026 Documentation Requirements Update

Key Changes in Group Therapy Documentation

Recent updates to documentation standards require providers to:

  1. Individual Progress Notes: Each group member must have individualized documentation reflecting their specific participation and progress
  2. Measurable Treatment Outcomes: Notes must connect to individualized care plans with measurable goals
  3. Individual Contributions: Document each patient's engagement, interventions directed at them, and their responses
  4. Medical Necessity: Establish and maintain medical necessity for group therapy participation for each member

Why These Changes Matter

Insurance audits increasingly scrutinize group therapy documentation. Using identical or "cookie-cutter" notes for all group members is a major audit red flag and can result in:

  • Claim denials and recoupments
  • Fraud investigations
  • Loss of provider credentials
  • Potential legal liability

CPT Codes for Group Therapy

CPT 90853: Group Psychotherapy

The primary billing code for group therapy.

Requirements per CMS Guidelines:

  • Group Size: Maximum 10 participants for Medicare/Medicaid
  • Duration: Typically 45-60 minutes
  • Individual Plans: Each member must have documented treatment plan
  • One Session Per Day: Generally bill once per client per day
  • 2025 Medicare Reimbursement: Approximately $28.14

Medical Necessity: Documentation must clearly demonstrate:

  • Why group therapy (vs. individual) is appropriate
  • How the group setting benefits this specific patient
  • Connection to patient's diagnosis and treatment goals

CPT 90849: Multiple-Family Group Psychotherapy

Used for group sessions involving multiple families or couples.

Requirements:

  • Must involve family members/support persons
  • Document both patient and family participation
  • Each patient family unit needs separate documentation

CPT 90846/90847: Family Therapy

For family sessions without or with patient present (not group billing, but related):

  • 90846: Family without patient present
  • 90847: Family with patient present

SOAP Note Structure for Group Therapy

Group therapy SOAP notes should follow a modified structure that captures both individual and group elements.

Subjective Section (S) for Group Therapy

Document individual patient's presentation to the group:

Individual Elements:

  • Patient's reported mood and current concerns
  • Issues brought to the group
  • Self-reported progress since last session
  • Relevant events since last group meeting

Group Context:

  • Topics patient wished to address in group
  • Patient's stated reaction to group themes

Subjective Section Components

Group Therapy Subjective Components
 
 
SUBJECTIVE SECTION - GROUP THERAPY
 
1. PATIENT PRESENTATION
- Mood upon arrival
- Affect observed
- Willingness to participate
- Example: 'Patient arrived appearing anxious, reported increased work stress since last session'
 
2. CONCERNS RAISED
- Issues brought to group
- Current stressors
- Example: 'Patient shared ongoing conflict with spouse, seeking feedback from group'
 
3. SELF-REPORTED PROGRESS
- Progress on goals since last session
- Homework/skill practice attempts
- Example: 'Patient reported attempting deep breathing exercises 3 times this week with moderate success'
 
4. INTERPERSONAL CONTEXT
- Relationships with group members
- Comfort level in group
- Example: 'Patient expressed feeling more comfortable sharing after two months in group'
 

Objective Section (O) for Group Therapy

Document observable behaviors and participation:

Individual Observations:

  • Level of engagement and participation
  • Verbal contributions (quantity and quality)
  • Non-verbal behavior and affect
  • Interactions with other group members
  • Response to feedback from group/therapist

Session Context:

  • Group session details (date, time, duration)
  • Number of participants present
  • Group's overall theme/focus
  • Interventions used by therapist

Objective Section Components

Group Therapy Objective Components
 
 
OBJECTIVE SECTION - GROUP THERAPY
 
1. SESSION DETAILS
- Date and time
- Duration: __ minutes
- Participants present: __/__ (e.g., 8/10)
- Group type: [Process/Psychoeducational/Support/Skills]
- Example: 'Group session 12/27/2025, 60 minutes, 8 of 10 regular members present'
 
2. PATIENT PARTICIPATION
- Engagement level: [Minimal/Moderate/Active/Highly Active]
- Verbal contributions: [Frequency and nature]
- Example: 'Patient participated actively, speaking approximately 5 times during session'
 
3. OBSERVABLE AFFECT/BEHAVIOR
- Affect throughout session
- Non-verbal cues
- Changes during session
- Example: 'Patient's affect shifted from anxious to calmer after receiving group support'
 
4. INTERPERSONAL INTERACTIONS
- Quality of interactions with peers
- Ability to give and receive feedback
- Example: 'Patient offered supportive feedback to two other members; received feedback about communication patterns with openness'
 
5. THERAPEUTIC INTERVENTIONS DIRECTED AT PATIENT
- Specific interventions used
- Therapist interactions with this patient
- Example: 'Therapist used cognitive restructuring to address patient's catastrophic thinking about work situation'
 
6. RESPONSE TO INTERVENTIONS
- How patient responded to feedback/interventions
- Insight demonstrated
- Example: 'Patient demonstrated insight, identifying pattern of avoidance in conflict situations'
 

Assessment Section (A) for Group Therapy

Connect observations to individual treatment goals:

Individual Assessment:

  • Progress toward individual treatment goals
  • Benefit from group participation this session
  • Clinical impressions specific to this patient
  • Prognosis and group therapy appropriateness

Group Context:

  • How group dynamics affected this patient
  • Patient's contribution to group process

Assessment Section Components

Group Therapy Assessment Components
 
 
ASSESSMENT SECTION - GROUP THERAPY
 
1. DIAGNOSTIC STATUS
- Primary diagnosis
- Symptoms addressed in group context
- Example: 'Generalized Anxiety Disorder (F41.1) - Patient's anxiety symptoms remain moderate but showing improvement in group setting'
 
2. PROGRESS TOWARD GOALS
- Reference specific treatment plan goals
- Measurable progress indicators
- Example: 'Goal 1 (Improve interpersonal communication): Progressing - patient demonstrated assertive communication in group today, up from passive responses in previous sessions'
 
3. THERAPEUTIC BENEFIT
- How patient benefited from this session
- Insights gained
- Skills practiced
- Example: 'Patient benefited from peer feedback regarding communication patterns; expressed new awareness of tendency to avoid conflict'
 
4. GROUP THERAPY APPROPRIATENESS
- Continued medical necessity for group format
- How group setting uniquely benefits patient
- Example: 'Group therapy remains appropriate; patient benefits from peer support and opportunity to practice interpersonal skills in safe environment'
 
5. CLINICAL IMPRESSIONS
- Overall assessment of patient's status
- Concerns or observations
- Example: 'Patient making steady progress in managing anxiety symptoms; demonstrates increased willingness to accept feedback'
 

Plan Section (P) for Group Therapy

Document individualized next steps:

Individual Plan:

  • Homework or between-session tasks
  • Skills to practice
  • Goals for next session
  • Need for individual sessions or other treatment

Group Continuation:

  • Continued participation recommendation
  • Any changes to group placement
  • Coordination with individual treatment

Plan Section Components

Group Therapy Plan Components
 
 
PLAN SECTION - GROUP THERAPY
 
1. CONTINUED GROUP PARTICIPATION
- Recommendation for continued attendance
- Frequency
- Example: 'Continue weekly group therapy; patient benefiting from current group composition'
 
2. HOMEWORK/BETWEEN-SESSION TASKS
- Specific, individualized assignments
- Skills to practice
- Example: 'Practice assertive communication technique discussed in group at least twice this week; journal about experiences'
 
3. GOALS FOR NEXT SESSION
- Topics to address
- Focus areas
- Example: 'Next session: Follow up on assertiveness practice; explore underlying beliefs about conflict'
 
4. INDIVIDUAL THERAPY COORDINATION
- Connection to individual sessions (if applicable)
- Communication with other providers
- Example: 'Will coordinate with individual therapist regarding anxiety management techniques'
 
5. TREATMENT PLAN UPDATES
- Any needed modifications to treatment goals
- Example: 'Treatment plan goal 1 updated to include assertiveness skill development based on session insights'
 
6. CRISIS/SAFETY PLANNING
- If applicable, safety concerns and plan
- Example: 'No safety concerns noted; patient denies SI/HI'
 

Complete Group Therapy SOAP Note Example

Complete Group Therapy SOAP Note
 
 
GROUP THERAPY PROGRESS NOTE
 
Patient: Jane Doe DOB: 01/15/1985
Date of Service: 12/27/2025 Time: 2:00 PM - 3:00 PM
Group Name: Anxiety Management Skills Group
Session #: 12 Duration: 60 minutes
Participants Present: 8 of 10 regular members
CPT Code: 90853 Diagnosis: F41.1 (Generalized Anxiety Disorder)
 
═══════════════════════════════════════════════════════════════
 
SUBJECTIVE:
 
Patient arrived to group on time, appearing somewhat tense but engaged. She reported experiencing increased anxiety this week related to an upcoming work presentation. Since last session, patient stated she attempted the progressive muscle relaxation technique 'a few times' with 'some success.' Patient expressed wanting to discuss her fear of public speaking and receive feedback from the group on coping strategies. She reported her anxiety level as 7/10 at the start of session.
 
Patient shared that she has been avoiding thinking about the presentation, which she recognizes as a pattern discussed in previous sessions. She expressed frustration with herself for 'knowing better but still doing it.'
 
═══════════════════════════════════════════════════════════════
 
OBJECTIVE:
 
Session Details:
- 60-minute process-oriented anxiety management group
- 8 members present (2 absent with prior notification)
- Group climate was supportive and cohesive
 
Patient Participation:
- Engagement Level: Active
- Spoke 6 times during session, including one extended share (approximately 5 minutes)
- Non-verbal: Initial crossed arms and fidgeting; posture relaxed by mid-session
 
Observable Behavior:
- Affect: Anxious at start, transitioning to relieved and thoughtful by end of session
- Made appropriate eye contact with group members
- Nodded supportively during others' shares
- Voice tremor noted when discussing presentation; resolved after group support
 
Interpersonal Interactions:
- Received supportive feedback from 3 group members regarding her presentation anxiety
- Offered encouragement to another member struggling with workplace anxiety
- Appropriately received constructive feedback about avoidance pattern
 
Therapeutic Interventions Directed at Patient:
- Cognitive restructuring: Examined catastrophic predictions about presentation outcome
- Psychoeducation: Reviewed exposure hierarchy for public speaking anxiety
- Skills practice: Group role-played brief presentation practice with patient
 
Response to Interventions:
- Patient identified automatic thought: 'Everyone will think I'm incompetent'
- With guidance, generated alternative thought: 'Some nervousness is normal; I am prepared'
- Participated in brief role-play; reported anxiety decreased from 7/10 to 4/10 after practice
- Demonstrated insight into avoidance-anxiety cycle
 
═══════════════════════════════════════════════════════════════
 
ASSESSMENT:
 
1. Generalized Anxiety Disorder (F41.1) - Moderate, Improving
- Patient continues to experience anticipatory anxiety, particularly related to performance situations
- Symptoms showing improvement; patient utilizing skills learned in group
 
2. Progress Toward Treatment Goals:
- Goal 1 (Reduce anxiety from 8/10 to 4/10): Progressing - patient reports baseline anxiety now 5-6/10, down from 8/10 at intake
- Goal 2 (Implement 2+ coping skills regularly): Partially met - patient using PMR intermittently; needs consistency
- Goal 3 (Reduce avoidance behaviors): Progressing - patient shows insight into avoidance; attended group despite anxiety
 
3. Therapeutic Benefit This Session:
- Patient benefited from peer normalization of presentation anxiety
- Exposure practice (role-play) demonstrated effectiveness of behavioral approach
- Cognitive restructuring provided new perspective on catastrophic thinking
 
4. Group Therapy Appropriateness:
- Group therapy remains medically necessary and appropriate
- Patient benefits from peer support, normalization, and in-vivo social skills practice
- Group setting provides unique opportunity for graduated exposure to social anxiety triggers
 
5. Clinical Impression:
- Patient engaged and motivated; making measurable progress
- Avoidance pattern remains a treatment focus
- Good prognosis with continued group participation and skill practice
 
═══════════════════════════════════════════════════════════════
 
PLAN:
 
1. Continue weekly group therapy (90853) - patient benefiting from current placement
 
2. Homework Assigned:
- Practice presentation in front of mirror or trusted person at least twice before work presentation
- Continue PMR daily (set phone reminder)
- Use thought record to capture and challenge anxious thoughts about presentation
 
3. Goals for Next Session:
- Process outcome of work presentation
- Reinforce coping skills used
- Continue building exposure hierarchy
 
4. Coordination:
- Patient also attending individual therapy biweekly with Dr. Smith
- Will email summary to individual therapist with patient consent
 
5. Safety:
- No safety concerns; patient denies SI/HI/SIB
- Coping strategies identified and accessible
 
Next Group Session: 01/03/2026, 2:00 PM
 
_______________________________________________
Therapist Signature Date
License #
 

Types of Group Therapy and Documentation Variations

Process Groups

Focus: Interpersonal learning and group dynamics

Documentation Emphasis:

  • Member interactions and relationship patterns
  • Group cohesion and development
  • Individual's role in group dynamics
  • Transference and in-group relationships

Psychoeducational Groups

Focus: Teaching specific skills or information

Documentation Emphasis:

  • Topics covered
  • Patient's understanding of material
  • Skill acquisition and practice
  • Application to individual situation

Support Groups

Focus: Mutual support and shared experiences

Documentation Emphasis:

  • Patient's connection with group members
  • Support given and received
  • Sense of universality and hope
  • Coping strategies shared

CBT/DBT Skills Groups

Focus: Teaching cognitive-behavioral or dialectical behavior therapy skills

Documentation Emphasis:

  • Specific skills taught and practiced
  • Homework completion and review
  • Skill generalization to daily life
  • Individual barriers to skill use

Common Documentation Mistakes to Avoid

1. Identical Notes for All Members

Problem: Using the same note for every group member Solution: Individualize each note with patient-specific observations, participation details, and progress

2. Lack of Individual Progress Documentation

Problem: Only documenting group themes without individual progress Solution: Connect each patient's participation to their treatment goals

3. Missing Medical Necessity

Problem: Not documenting why group therapy (vs. individual) is appropriate Solution: Include statement on how group setting benefits this specific patient

4. Inadequate Session Details

Problem: Generic documentation without specific examples Solution: Include specific quotes, interactions, and interventions

5. No Treatment Plan Connection

Problem: Notes don't reference treatment plan goals Solution: Explicitly connect observations to individualized treatment goals

Free Group Therapy SOAP Note Template

GROUP THERAPY SOAP NOTE TEMPLATE
 
═══════════════════════════════════════
SESSION INFORMATION
═══════════════════════════════════════
Patient Name: _________________ DOB: _________
Date of Service: ______________ Time: ________
Group Name: __________________________________
Session #: _____ Duration: _____ minutes
CPT Code: 90853
Diagnosis: ___________________________________
Participants Present: ___/___
 
═══════════════════════════════════════
SUBJECTIVE
═══════════════════════════════════════
Mood/Presentation Upon Arrival:
 
Concerns/Issues Brought to Group:
 
Self-Reported Progress Since Last Session:
 
Goals for Today's Session:
 
═══════════════════════════════════════
OBJECTIVE
═══════════════════════════════════════
Participation Level: [ ] Minimal [ ] Moderate [ ] Active [ ] Highly Active
 
Observable Affect:
 
Verbal Contributions:
- Approximate frequency: ___ times
- Quality of contributions:
 
Non-Verbal Behavior:
 
Interpersonal Interactions:
- Feedback given to others:
- Feedback received:
 
Therapeutic Interventions Directed at Patient:
 
Response to Interventions:
 
═══════════════════════════════════════
ASSESSMENT
═══════════════════════════════════════
Diagnostic Status:
 
Progress Toward Treatment Goals:
- Goal 1: _____________ Status: ___________
- Goal 2: _____________ Status: ___________
 
Therapeutic Benefit This Session:
 
Group Therapy Appropriateness:
[ ] Continues to be medically necessary and appropriate
Rationale:
 
Clinical Impressions:
 
═══════════════════════════════════════
PLAN
═══════════════════════════════════════
1. Continue Group: [ ] Yes, weekly [ ] Yes, modified [ ] Discharge
2. Homework/Between-Session Tasks:
3. Goals for Next Session:
4. Coordination with Other Treatment:
5. Safety: [ ] No concerns [ ] Concerns addressed: ________
 
Next Session: ________________
 
═══════════════════════════════════════
Provider Signature: _________________ Date: _______
Credentials/License #: _________________
 

Billing Compliance Checklist

Group Therapy Billing Compliance Checklist
 
 
GROUP THERAPY BILLING COMPLIANCE CHECKLIST
 
BEFORE BILLING CPT 90853, VERIFY:
 
□ SESSION REQUIREMENTS
□ Session duration documented (typically 45-60 min)
□ Group size within limits (≤10 for Medicare/Medicaid)
□ Start and end time documented
□ Date of service correct
 
□ DOCUMENTATION REQUIREMENTS
□ Individual note for each patient (not identical copies)
□ Patient-specific participation documented
□ Connection to individual treatment goals
□ Medical necessity for group format established
□ Diagnosis supports group therapy
 
□ TREATMENT PLAN
□ Current treatment plan on file
□ Group therapy included in treatment plan
□ Individualized goals documented
□ Progress toward goals noted in session note
 
□ ONE SESSION PER DAY
□ Only one group session billed per patient per day
□ If multiple groups, documented as separate and distinct
 
□ SIGNATURES AND CREDENTIALS
□ Provider signature
□ Date signed
□ Credentials/license number
□ Signed within required timeframe
 
□ MEDICAL NECESSITY STATEMENT
□ Why group therapy is appropriate for this patient
□ How patient benefits from group setting
□ Continued need documented each session
 

Official Resources and References

CMS and Medicare

CPT and Billing

Clinical Guidelines

Related Guides

Frequently Asked Questions

Each group member requires individualized documentation that captures their specific participation, verbal contributions, interactions with other members, response to interventions, and progress toward their unique treatment goals. Avoid generic statements that could apply to any participant. Instead, include specific observations like direct quotes, behavioral examples, and measurable progress indicators tied to each patient's individual treatment plan.

While you can use a consistent template structure, the content must be individualized for each patient. Using identical or 'cookie-cutter' notes for all group members is a major compliance risk that can trigger insurance audits, claim denials, and fraud investigations. Each note should reflect that specific patient's presentation, participation level, therapeutic benefit, and progress toward their personal goals.

For Medicare and Medicaid, group psychotherapy sessions (CPT 90853) should have no more than 10 participants. Private insurers may have different requirements, so always verify with each payer. Document the number of participants present in each session (e.g., '8 of 10 regular members present') to demonstrate compliance.

Document specifically why group therapy is the appropriate treatment modality for each patient. Include how the group setting provides unique therapeutic benefits such as peer support, interpersonal learning, normalization of experiences, social skills practice in a safe environment, or feedback from multiple perspectives. This justification should appear in both the treatment plan and ongoing session notes.

Document the patient's non-verbal participation, including affect, body language, attentiveness, and reactions to others' shares. Note any brief verbal contributions or responses when addressed. Include your clinical interpretation of their participation level and whether it represents progress, regression, or consistency with their baseline. Document any interventions you directed toward them and their response.

Yes, AI-powered documentation tools like SOAPNoteAI.com can significantly streamline group therapy documentation. SOAPNoteAI is HIPAA-compliant with a signed Business Associate Agreement (BAA), offers an iPhone and iPad app for convenient mobile documentation, and works for any specialty including group therapy. It can help you quickly generate individualized notes for each group member while ensuring compliance with documentation requirements.

Focus on documenting each patient's experience of and contribution to group dynamics without revealing identifying information about other members. Use general references like 'another group member' or 'peers' rather than names. Document how the patient interacted with the group process, gave or received feedback, and responded to group themes, while keeping other members' specific disclosures confidential in that patient's note.

Medical Disclaimer: This content is for educational purposes only and should not replace professional medical judgment. Always consult current clinical guidelines and your institution's policies.

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