The session is one event. The chart obligation is per member. A 90-minute DBT skills group with eight people is eight notes. Copy-pasting the group focus and handwriting participation is what an audit picks at.
The format supports LCSW and LPC groups. The shared block records focus, intervention, and group dynamics. The member block records participation, response, treatment plan progress, and risk. Each chart gets a complete note.
Group session
- Date: [encounter_date]
- Facilitator(s): [provider_name] / [co_facilitator_name]
- Supervisor: [supervisor_name]
- Modality: DBT skills / CBT / process / psychoeducation / SUD relapse prevention / other
- Group format: open / closed
- Total members in attendance: [count]
- Duration: [duration]
- CPT (typical 90853 for group psychotherapy):
Shared group block (writes once)
- Group focus and topic:
- Curriculum or skill module covered (if applicable):
- Intervention or technique delivered:
- Group dynamic observed (cohesion, conflict, supportive interactions):
- Co-facilitation roles if applicable:
- Safety incidents during group: yes / no, with description if yes:
Per-member block (writes for each participant)
Member: [patient_name] DOB: [dob] Age: [age] Member ID in group: [member_id]
- Treatment plan goal addressed for this member:
- Attendance: present full / present partial / absent
- Affect and presentation in group:
- Participation level (engaged, observer, withdrawn, disruptive, supportive):
- Specific contributions or disclosures:
- Skill demonstration or practice in session:
- Response to intervention:
- Risk update (SI, HI, self-harm, substance use disclosure):
- Coordination needed with primary therapist or prescriber:
- Plan for next session or individual contact:
- Supervisor co-sign required (pre-licensure): yes / noAriaMD captures the group as one event and splits documentation across each participant’s chart. The shared block writes once. Speaker identification attributes participation, disclosures, and skill demonstration to the right member. Supervisor co-sign routes through the supervisor field. CPT 90853 is suggested by default. You sign each member note.