As shown, treatment planning software helps to reduce the admin burden on practitioners, allowing them to spend more quality time with patients. Below, a screenshot from the software Therapy Notes illustrates how some solutions, even those not designed with a dedicated Treatment Planning tool, can allow practitioners to customize goals and create bespoke treatments from common therapeutic goals.
Designed for clinicians and usable by practice staff, the solution is pre-loaded with DSM-5 and ICD diagnostic codes for quicker data entry. Among its many features is a Planning function that can be used to create bespoke plans for Wiley Treatment Plans.
These combine clinician-entered assessment information with practitioner templates for a quicker, more comprehensive process than manual planning. It offers a wealth of customizable templates for different mental health subdisciplines, each of which can be edited to detail care elements such as goals, interventions, presenting problems, patient strengths, and barriers.
The system comes with a comprehensive database of codes and more to choose from. While treatment planning software can absolutely add value in large practices such as hospitals or e-clinics, it often comes with a monthly subscription, and even then the available features may not address your specific needs.
For this reason — among others — software with custom form capabilities can be a useful solution. These simple documentation tools can be found in most behavioral health and coaching solutions, and give practitioners the flexibility to create their own treatment plan templates by creating separate forms for various key fields.
According to Health and Welfare Idaho, there are four types of form that can cover the essential fields of a versatile treatment plan: [5]. Whether a digital clinical solution will be valuable in your organization, or whether you opt for custom forms, it helps to know that there are many great options available for you as a mental healthcare practitioner.
Copies of the revised plan should be given to the consumer and support person, nominated person, guardian and carer as appropriate. Office of the Chief Psychiatrist. Office of the Chief Mental Health Nurse. Skip to main content. Treatment plans. On this page. Key messages Definitions Purpose and scope Mental Health Act principles Treatment plan principles Preparing to write a plan Writing a plan Indicators for quality audits Appendix: Mental health treatment plan.
Key messages Treatment planning processes must be undertaken and documented for every consumer of public mental health services, regardless of their legal status. Consumers should be involved in all decisions regarding their treatment and recovery and should be supported to make or participate in those decisions and have their views and preferences respected.
Nominated persons, families and carers should be involved in treatment planning. Treatment planning documentation must be shared with consumers.
Purpose and scope This new guideline has been developed in response to a recommendation made in the Chief Psychiatrist's Audit of inpatient deaths to set a minimum standard for treatment planning in mental health services. Mental Health Act principles When participating in treatment planning, service providers must have regard to the mental health principles, as expressed in the Mental Health Act Treatment plan principles Treatment planning should: be led by consumers and respond to their identified recovery goals and preferences be recovery-oriented and strengths-focused include all people involved in the consumer's mental health care, including the treating team, carers, guardians, support persons and nominated persons be documented on a specific template be written in language that is easy to understand, with a copy provided to the consumer.
Preparing to write a plan Timing Treatment planning starts as soon as possible after a consumer enters a mental health service. Supported decision making Information should be provided to consumers in a way that they understand to ensure they can adequately weigh up the risks and benefits of treatment and consider treatment options.
Consent to treatment The treatment plan will be shaped by issues of consent to treatment, bearing in mind the need for consumers to be supported to make their own informed decisions wherever possible. A person has capacity to give informed consent to treatment if they: understand the information they are given that is relevant to the decision remember this information use or weight the information communicate the decision they make by means of speech, gestures or any other means.
Assessment orders Treatment while an assessment order is in place should only be provided if: the person gives informed consent to the treatment, or a registered medical practitioner is satisfied that urgent treatment is necessary to prevent serious deterioration in the mental or physical health of the person or serious harm to the person or to another person. Information sharing Developing a comprehensive treatment plan may benefit from sharing information with other healthcare providers general practitioners, psychologists and private psychiatrists and carers, guardians, support persons and nominated persons, where they exist.
The circumstances under which a patient's health information can be disclosed to other parties include situations where: the person to whom the information relates consents to its disclosure this disclosure is reasonably required by a carer of the patient to determine the nature and scope of the care to be provided to the patient and to make the necessary arrangements in preparation for that role and to provide care to the patient, having regard to the patient's views and preferences, including those expressed in any advance statement this disclosure is required by another mental health service provider, or health service provider, to provide health services to the patient.
Enlisting consumer supports Consumers should be encouraged to include support persons and nominated persons in these discussions. Treatment plan meetings Treatment planning can take place in a variety of circumstances and settings for example, a clinical review or family meeting provided consumers are present and have given their consent to the presence of a carer, guardian, support person, nominated person, independent mental health advocate or interpreter.
Consumers must be given time and support to: express their goals, values and preferences regarding treatment disagree with treatment if they wish contribute to treatment decisions as much as possible. Writing a plan Individual and cultural needs When writing a treatment plan, the consumer's individual needs and preferences are paramount. Content of plans Treatment plans should: prioritise the consumer's recovery goals and immediate needs, with a focus on self-determination, strengths and aspirations identify potential risks, including plans to mitigate them list treatment strategies and objectives, and alternatives that have been considered state what the service will do to address identified needs, who is responsible for each action, timeframes and expected outcomes summarise the consumer's opinion of the treatment plan include steps to meet carers' needs where applicable.
Documentation While services are free to record treatment planning discussions in a variety of formats, a template is provided for convenience see appendix. Subsequent plans should include more detail and specify the discharge plan and follow-up care. Implementation Where reasonably practicable, the authorised psychiatrist should personally discuss the plan with the consumer, but this can be delegated if required to the case manager, treating doctor or another appropriate member of the treating team.
Review Treatment planning is an ongoing process. Indicators for quality audits The following indicators are suitable to use in audits of compliance with this guideline: a local treatment plan policy and procedures document for clinicians a timeline for reviewing the policy and procedures document the proportion of consumer files that include: evidence of consumer involvement evidence of consumer self-direction evidence of supported decision making evidence of family and carer involvement, where appropriate evidence that the consumer was provided with a copy of the plan evidence for community consumers that the plan was reviewed within 91 days.
This is where you have the opportunity to explain what is expected of them and that you're not there to simply "fix" anyone. Therapy is often hard work but can have amazing results.
Another aspect of treatment planning that is so often forgotten in private practice settings is the client's support system. It's not just you and the client against the world. They'll need other supports in place to be successful throughout life.
Identify any support as part of your treatment plan and you have already shown your client some of the tools in their toolbox.
Get creative here. Perhaps the client's support is a family member or friend but it could also be a pet or a support group. Maybe it's a hobby or spiritual practice that helps keep them grounded. Perhaps some character traits like being fiscally responsible, planning ahead or being very outgoing or creative. These are all supportive things that help the client reach their goals.
The last important aspect of the written plan is the outcomes, or success. Make sure to write these down at various intervals. Maybe you visit the outcomes so far once a month, maybe every three months, etc.
Choose what interval works best for your client and your style and make sure to plan to talk with them about it. Is this still the primary goal or do we need to adjust something? Are we staying on track with these? If not, is time to redirect or do we need to revisit some things? What success have we made and what contributed to that? A treatment plan is simple but specific.
Although treatment plans vary, a treatment plan template or form generally contains the following fields:. A treatment plan is a detailed plan tailored to the individual patient and is a powerful tool for engaging the patient in their treatment.
Treatment plans usually follow a simple format and typically include the following information:. The purpose of a treatment plan is to guide a patient towards reaching goals. A treatment plan also helps counselors monitor progress and make treatment adjustments when necessary. You might think of a treatment plan as a map that points the way towards a healthier condition.
Without a treatment plan, a patient has no clear direction on how to improve behaviors, negative thinking patterns, and other problems impacting their lives. Treatment plans provide structure patients need to change. Model and technique factors account for 15 percent of a change in therapy.
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