Question
What elements should be included in the documentation of group therapy sessions?
Answer
Effective documentation of group therapy sessions is essential for maintaining compliance with Medicare guidelines and ensuring transparency in treatment. Therapists must clearly outline the justification for using group therapy, explaining why this approach was chosen over individualized care. This justification should describe how group therapy benefits each patient, whether by improving motivation, providing socialization opportunities, or enhancing functional outcomes through shared activities. By explicitly linking the therapy format to patient goals, therapists can demonstrate the clinical appropriateness of the session.
In addition to the rationale for group therapy, documentation must include details about the session itself. This includes the specific activities performed, the session duration, and each participant's individual contributions. Therapists should also record how the group session aligns with each patient’s treatment plan and functional goals. For instance, if the goal is to improve lower body strength, the documentation should specify exercises performed, resistance levels, and observable progress. Thorough documentation supports compliance during audits and serves as a communication tool for other clinicians involved in the patient’s care.
This Ask the Expert is an edited excerpt from the course, "Strategic Application of Group and Concurrent Therapy in Long-Term Care," presented by Kevin Cezat, PT, DPT, GCS, RAC-CT.
