Group Therapy Documentation: A Mental Health Practitioner Guide
Group therapy notes need to capture the group as a whole, each member's participation, and any incidents or risk concerns — without breaching members' privacy across each other's files. This guide details the dual-record structure.
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Summary
Group therapy creates a documentation challenge: the group itself is a clinical entity, but each member also needs an individual record. Best practice is a dual-record structure — a group session note that captures shared content, plus brief individual notes that capture member-specific participation, risk, and progress. Group notes must never name other members in any individual file.
The dual-record structure
Group session record
- Date, duration, modality (in-person, telehealth).
- Facilitators present.
- Members attending (initials only or member numbers — not full names linked back to other members' files).
- Topic / module of the session.
- Content delivered.
- Group-process observations (cohesion, conflict, themes).
- Any group-level incidents.
- Plan for next group.
Per-member note
- Date and group reference.
- Member's attendance and engagement.
- Member-specific content shared.
- Member's response to the topic.
- Risk assessment (for that member).
- Plan / homework.
- Any communication with the member's individual therapist or referrer.
The per-member note should not mention other members by name, identifying detail, or clinical information. If a member's behaviour affected another member, document only your management of it (e.g. "discussed group safety expectations") in the affected member's file, with the detail in the group session record.
Privacy considerations
A subpoena directed at one member's file should not deliver clinical information about other members. The dual-record structure protects against this provided the per-member notes are scrupulously confined to that member.
CBT and DBT group programs
Manualised group programs (e.g. CBT-i, DBT skills group) often have prescribed session structures and homework. Notes should reference the manual session number and the components covered, plus any deviation from the manual.
Related reading
MBS items covered in this guide
Documentation tests, descriptor conditions, and common audit failures.
How we review this guide
Library guides reference original Australian source authorities — not secondary commentary — and are updated when source material changes. Each guide cites the regulator, item descriptor, or governing standard it draws from so you can verify it directly.
- Sources checked
- Original Australian source authorities and peer-reviewed guidance
- Review cadence
- Reviewed annually and whenever a cited source authority publishes a material change. Last reviewed .
- Not advice
- Reference content for Australian practitioners and education staff. Not legal, clinical, or billing advice — verify against your governing body and current source documents.
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