Treatment Planning
Each program has a multidisciplinary approach
to treatment planning. Those involved in the treatment planning process, based
on the program, may include the patient’s physician, nursing staff, social workers,
counselors, certified substance abuse counselors, mental health technicians,
teachers and activity therapists. The team is responsible for development of
the individualized treatment plan and the review and evaluation of ongoing treatment.
Preliminary Treatment Plan
The primary nurse, physician or designee initiates
the preliminary treatment plan upon admission. It is based on the intake assessment,
nursing assessment and physician’s orders. It includes the following:
- Identification of initial problems, symptomatic
behavior of the problem, and assessment of the cause of the problem
- Goals of treatment
- Measurable short-term objectives based on
the goals of treatment
- Therapeutic approaches (interventions) to
be used with the patient
- Accountable members of the treatment team.
Master Treatment Plan
The master treatment plan is formalized no later
than three days after admission for acute care, and within seven days for the
PHP. The treatment plan is a reflection of our philosophy of treatment and incorporates
interdisciplinary input and collaboration of all team members. It includes the
following:
- Identification of physical, psychological
and social problems the patient is experiencing
- Prioritization of patient needs and care
- Achievable long-term goals of treatment stated
in behavioral terms
- Measurable short-term goals stated in behavioral
terms that will reflect progress toward the goal achievement
- Therapeutic approaches (interventions) used
by each discipline to assist the patient in meeting the treatment goals
- The individual or discipline accountable for
assisting the patient with the therapeutic approaches
- Patient progress in meeting the treatment
plan goals is documented in the progress notes. The nursing staff and case
manager, or therapist in the outpatient settings, are responsible for noting
the treatment method, as well as decisions and revisions of the treatment
plan by the treatment team, both at meetings and on an ongoing basis.
The patient, and family when appropriate, is
encouraged to participate in the treatment planning process by providing input
and acknowledging agreement with the plan in writing. Conflicts in care decisions
and resolutions of dilemmas about care decisions are addressed cooperatively
by the team members and the patient and/or family.
Treatment plans are reassessed by the team at
regular intervals and revised as needed.
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