How to Write Individual Treatment Plans
Treatment plans in health, dental and mental health practice provide important benefits. They identify problem areas, establish goals and objectives, detail the treatment options most likely to resolve or ameliorate problems and establish timelines. Plans inform patients and their families, practitioners and relevant others, such as insurance company representatives, of the potential and means for improving a patient's status. They keep everyone's focus and allow practitioners who see a patient for the first time to orient themselves quickly to the patient's care.
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Instructions
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Establish the presenting problems and the patient's history. Write out the principal reason the patient gives for seeking health-related assistance. Record beliefs she may express about her condition or illness. For example, the patient might state that the rash over her entire body is the result of something she ate at a restaurant two days before.
Include information about her living arrangements, social support, employment, social and religious beliefs and medical history. Her medical history should include such data as current medications, allergies and observable physical condition. List recent illnesses, surgeries and hospitalizations.
Include any diagnoses that have been determined. If no definitive diagnosis is the basis for treatment, list the diagnoses being considered, as well as interim treatment regimens.
Modify the treatment plan when additions or changes to the patient's history occur. Record new data from test results that lead to a more specific diagnosis and course of treatment.
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Describe goals as positive restatements of problem areas. You might record a goal that states the patient will return home free of pain from his injury. Objectives are written as short- or long-term measurable statements. An objective might state that within two days of starting treatment, a patient's temperature will go no higher than 100 degrees.
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Describe the orders that the attending physician has prescribed. Include any signs or symptoms to watch for, medications to administer, in what dosages and intervals, and any procedures to complete, such as replacing a drainage tube every eight hours or changing a bandage as needed. Identify medications that are administered as needed, such as a pain medication. Indicate that standard procedures are to be followed, such as recording vital signs every hour, instead of listing each activity individually.
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Record the anticipated timeline. Indicate when various treatments will begin and the probable date of the patient's discharge.
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Get written consent for their treatment plans from patients whenever feasible.
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