Psychiatrists, psychologists, mental health counselors, social workers, and other behavioral health professionals use treatment planning as a tool to effectively treat patients.
Without a clear plan in place, it can be hard to track progress, stay organized and keep a record of individual patient care.
Every patient needs individually tailored treatment. When a mental health professional creates a comprehensive treatment plan specially designed to meet their patient's needs, they give their patient directions towards growth and healing.
Although not all mental health professionals are required to produce treatment plans, it's a beneficial practice to both the counselor and the patient.
In this guide, we'll show you why mental health treatment plans are essential and how to create psychiatric treatment plans that will make a difference in your and your patient's lives.
What is a Treatment Plan?
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 patient's personal information, psychological history and demographics
- A diagnosis of the current mental health problem
- High-priority treatment goals
- Measurable objectives
- A timeline for treatment progress
- Space for tracking progress
What is the Purpose of a Treatment Plan?
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. Research shows that focus and structure are critical parts of positive therapy outcomes.
Goal-setting as part of a treatment plan is beneficial in itself.
Setting goals helps patients:
Avoid Feeling Overwhelmed
Treatment plans also help therapists and behavioral health staff with documentation.
Treatment plans contain essential information about a patient's progress in a clear and organized format with details such as dates, names, and measurable goals.
With this information readily available, writing a progress note becomes an easier part of the job.
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The Goals and Objectives of Mental Health Treatment Plans
Treatment planning is a team effort between the patient and the counselor.
Both parties work together to create a shared vision and set attainable goals and objectives. A goal is a general statement of what the patient wishes to accomplish.
Examples of goals include:
- The patient will learn to cope with negative feelings without using substances.
- The patient will learn how to build positive communication skills.
- The patient will learn how to express anger towards their spouse in a healthy way.
An objective, on the other hand, is a specific skill a patient must learn to reach a goal. Objectives are measurable and give the patient clear directions on how to act.
Examples of objectives include:
- An alcoholic with the goal to stay sober might have the objective to go to meetings.
- A depressed patient might have the objective to take the antidepressant medication with the goal to relieve depression symptoms.
- A patient in a recovery program might have the objective to keep a daily assertiveness log with the goal to learn healthy communication skills.
Simply said, an objective is a specific way to reach a goal.
Tips for Identifying Goals & Objectives for Patients
Everyone is different, and so is every treatment plan. A counselor must use their skills to help a client establish the best goals and objectives for their unique condition.
Counselors can ask themselves these questions to help uncover the best goals for their patients:
- What is the patient doing that is unhealthy?
- What does the patient need to do differently to change unhealthy behavior?
- How can I help the patient adopt new behaviors?
After you've realized the goals, you can determine the objectives by asking yourself:
- What does the patient need to do to accomplish the goals?
- What can I do to help them with objectives?
Patients play an important role in developing their treatment plan.
Although you will use your professional knowledge to facilitate treatment planning, patients must participate in the following ways:
- The patient must understand they have a problem.
- They must understand precisely what their problem is and how it affects them.
- They must be willing to learn skills to solve the problem in a healthy way.
How to Write A Mental Health Treatment Plan
Goal-setting is only part of the treatment plan process.
You'll need to gather information and conduct a mental health assessment before creating a treatment plan. You'll also need to identify and discuss possible goals with your patient.
After an assessment and discussion, you'll be ready to create a treatment plan which both you and your client will need to sign.
Treatment planning is an ongoing process. You'll review and revise the treatment plan as needed and nothing is written in stone.
A mental health treatment plan template will help you stay organized, but the information it holds is unique to the client and open to changes.
1. Treatment Plan Template
A treatment plan is simple but specific. Although treatment plans vary, a treatment plan template or form generally contains the following fields:
- Patient information: At the top of the treatment plan, the counselor will fill in information such as the patient's name, social security number, insurance details, and the date of the plan.
- Diagnostic summary: Next, the counselor will fill out a summary of the patient's diagnosis and the duration of the diagnosis.
- Problems and goals: The third section of the treatment plan will include issues, goals, and a few measurable objectives. Each issue area will also include a time frame for reaching goals and completing objectives. Counselors should strive to have at least three goals.
- Signatures: The final section of the treatment plan is where the counselor and the client sign their names. This signifies that the patient participated in developing the treatment plan and agrees with the content.
2. Mental Health Treatment Plan Checklist
To ensure you don't miss any crucial details, use this checklist as a helpful reminder:
- Issues: Do the issues reflect the six problem domains which are medical status, employment, substance abuse, legal status, family or social status and psychiatric status? Are issues written in behavioral terms and a non-judgmental manner? Are they prioritized?
- Goals: Do the goals address the listed issues? Are they attainable during treatment? Does the patient understand the goals as written? Does the client seem ready to change and accomplish the goals?
- Objectives: Do the objectives address the goals? Are the objectives measurable and specific? Can the client take the time or steps necessary to complete objectives? Is there a time frame for the objectives? Are they realistic for the patient's current situation? Does the client understand what is expected of them?
- General: Is the treatment plan customized to suit the patient based on their unique skills, goals, lifestyle, educational background, culture and socioeconomic status? Are their strengths incorporated in the treatment plan? Has the patient participated in developing the plan? Is the plan dated and signed by all parties who were involved in creating the treatment plan?
Mental Health Treatment Plan Tips
There are no set rules for developing a treatment plan for your patient because every plan is unique.
However, we'll look at a few tips to help you through the goal-setting and planning process.
1. Measure Success
To evaluate the effectiveness of the treatment plan, you need to keep a score of how the patient is doing. Ask the patient to count and keep track of their thoughts, feelings, and behaviors in a log so you can monitor their progress.
2. Set SMART Goals
Work with your patients to set goals and objectives they can actually reach. Use the rules of SMART for guidance. SMART stands for the following:
- Specific: Objectives need to be clear and specific, not general or vague. It's easier for a patient to complete objectives when they know exactly what they need to do.
- Measurable: Objectives need specific times, amounts or dates for completion so you and your patients can measure their progress.
- Attainable: Encourage patients to set goals and objectives they can meet. If their objectives are unrealistic, it may decrease their self-confidence or discourage them. However, goals and objectives should not be too easy either. Goals should be challenging but also realistic.
- Relevant: Goals and objectives should be relevant to the issues listed in the treatment plan. When patients complete objectives and reach their goals, they should be closer to the place they want to be in life and as a person.
- Time-bound: Goals and objectives must have a deadline. Goals might be considered short-term or long-term, while objectives need specific dates to meet. A deadline creates a sense of urgency which helps motivate clients.
3. Set Goals That Motivate
Patients are more likely to complete objectives and work towards reaching a goal if the goal is personally important to them. If a goal does not add value or meaning to their life, they will not have the motivation to work through objectives.
Ask clients to discuss goals that have the most meaning to them. Make sure the goals are in order of importance so patients can focus on their priorities.
How a Mental Health Treatment Plan Complements Other Therapy Notes
Treatment plans not only help the patient but also serve the entire behavioral health team.
A treatment plan is a tool that promotes good communication between staff members and helps provide the documentation necessary for billing.
As part of a patient's medical health records, treatment plans also help facilities comply with federal and state laws. Let's look at a few ways mental health treatment plans assist with recordkeeping.
1. Psychiatric Evaluation
A psychiatric evaluation involves using tools to measure and observe a client's behavior. By evaluating a client, a psychologist can determine a diagnosis and develop a treatment plan. A treatment plan helps organize this information in one neat document. The treatment plan also allows for quick reference of the initial evaluation when staff members or counselors need to revisit the evaluation in the future.
2. Progress Notes
Treatment plans and progress notes tend to go hand in hand because progress notes need to incorporate one or more treatment objectives. Progress notes are essential for communicating patient care and getting reimbursed for services. A treatment plan helps staff meet progress note requirements and keep track of how a patient is doing. Progress notes typically include:
- The treatment plan
- Any changes in the client's condition
- Descriptions of a client's response to treatment
- The outcome of treatment
3. Discharge Summary
When patients are ready to leave a treatment program, a discharge summary is needed to document how the patient completed treatment and what their plan for continuing care is. A treatment plan can guide the writing process when it's time to produce an accurate, detailed discharge summary.
Create a Mental Health Treatment Plan With ICANotes
Electronic health record (EHR) software allows medical professionals to store vital documents, such as treatment plans, evaluations, and discharge summaries digitally in an organized, user-friendly format.
ICANotes is EHR software designed specifically for the behavioral health field. With ICANotes, you can easily and quickly create unique treatment plans for your patients.
You can also use ICANotes' EHR software to record the initial assessment, make progress notes and write a discharge summary all in the same place.
The treatment plan module includes the following features:
- Easy-to-use interface: An intuitive, user-friendly interface makes it easy to create a treatment plan in a few simple steps with minimal typing.
- Comprehensive lists: Select from a list of 32 common mental health problems, long-term and short-term goals for each problem and also intervention content for each goal. Users can also customize treatment plans if problems or goals are not on the lists.
When patients are ready to leave treatment, you can use ICANotes to quickly and effortlessly create a discharge summary.
The discharge summary module prints a cover page with the initial assessment, provides the option to include all progress notes in a compressed format, and contains the final diagnosis and discharge instructions.
Proper documentation does not need to be a stressful, time-consuming part of the job.
ICANotes Behavioral Health EHR offers benefits such as:
Whether it's time to get reimbursed or undergo an audit, you'll be ready to supply accurate, legible, and detailed information upon request.
That way you can keep your practice running smoothly and have plenty of time left over for your patients.
Clinical Director October has been a Registered Nurse for over 15 years. She is board certified in Mental Health and Psychiatric Nursing. She holds a Bachelor of Arts from the University of North Carolina at Greensboro. She also graduated with bachelor and master degrees in Nursing from Western Governors University.